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Source: VA State Licensing Agency
Type of inspection: Renewal. Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/14/2025 11:10 a.m.-1:10 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: none all were attending day support programs today The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: NA Number of interviews conducted with staff: 2 Observations by licensing inspector: Tour of physical plant, physician's orders, medication administration records, emergency supplies, first aid kit Additional Comments/Discussion: Staff members were given the opportunity to ask questions An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Belinda Dyson, Licensing Inspector at (804 662-9780 or by email at Belinda.Dyson@dss.virginia.gov
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/26/2024 10:30 a.m.-12:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: none, all were attending day support programs The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 2 Number of interviews conducted with residents: none Number of interviews conducted with staff: 1 Observations by licensing inspector: physician?s orders, medications, medication administration records Additional Comments/Discussion: Administrator was given the opportunity to ask questions An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Belinda Dyson, Licensing Inspector at (804) 662-9780 or by email at Belinda.Dyson@dss.virginia.gov
Type of inspection: Renewal Date(s) of inspection: 1) 02/03/2023, 2) 02/05/2023, 3) 02/06/2023, and time the licensing inspector was on-site at the facility for each day of the inspection: 1) 8:21 a.m. ? 8:40 a.m., 2) 12:30 p.m.- 2:30 p.m., 3) 5:49 p.m.- 6:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 06 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 03 Number of staff records reviewed: 02 Number of interviews conducted with residents:02 Number of interviews conducted with staff: 02 Observations by licensing inspector: buildings/grounds, record reviews, first aid kit, training records, emergency food supplies, medication administration observation, and meal observation. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Vashti Colson, Licensing Inspector at (804) 662-9432 or by email at Vashti.Colson@dss.virginia.gov
VIOLATION: Based upon, the staff interviews and contact, the facility failed to ensure that all records shall be made available for inspection by the department's representative. EVIDENCE: During the February 2, 2023, renewal visit, the facility failed to have the resident and staff records available for inspection by the department?s representative.
VIOLATION: Based upon observation during the building tour, the facility failed to have all medications stored in a cabinet, container, or compartment that shall be used for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility. Medications shall be stored in a manner consistent with current standards of practice. EVIDENCE: During the February 2, 2023, renewal inspection visit, it was noted that the front desk had a sealed pharmacy bag laying on top of the desk with medication enclosed. Staff #2 informed the licensing representative that the medication was delivered yesterday (2/1/2023) to the facility by the pharmacy and that the item was placed on the front desk counter for the Med Tech to process upon her return.
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/10/2022 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 6 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 03 Number of staff records reviewed: 02 Number of interviews conducted with residents: Interviews conducted during the inspection. Number of interviews conducted with staff: 03 Observations by licensing inspector: Medication pass Additional Comments/Discussion: N/A The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Vashti Colson, Licensing Inspector at (804) 662-9432 or by email at Vashti. Colson @dss.virginia.gov
VIOLATION: Based upon the record review, the facility failed to have each resident or the resident's legal representatives sign and date the individualized service plan. EVIDENCE: The individualized service plan for resident #1 , dated 12/05/2021 , failed to have the signature of the resident or the signature of the resident's representative.
VIOLATION: Based upon the record review, the facility failed to review annually the resident's rights and responsibilities with each staff member. EVIDENCE: One out of two staff records reviewed failed to have an updated annual resident rights and responsibilities. Staff #2 last resident rights and responsibilities review date was 09/09/2019.
VIOLATION: Based upon the record review, the facility failed to maintain a current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. EVIDENCE: Two out of two staff records reviewed failed to have a current certification in first aid.
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