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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: 8-5-25 from 10:15 a.m.- 3:45 p.m. and 8-12-25 from 8:45 a.m.-12:15 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: 53 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Additional Comments/Discussion: The following items were also reviewed/observe during the inspection-facility documentation, facility postings, first aid kit, medication pass, physician?s orders, medication administration records, lunch meal/menu. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Based on a review of resident records the facility failed to ensure that upon admission, the assisted living facility shall provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his/her legal representative, and such documentation shall be kept in the resident's record. Evidence: The record for Resident # 4 (admit date: 8-20-24) did not contain documentation of the acknowledgment of having received the orientation. This was confirmed by facility staff.
Based on a review of resident records the facility failed to ensure that prior to his/her admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. The physician shall be board certified or board eligible in a specialty or subspecialty relevant to the diagnosis and treatment of serious cognitive impairments (e.g., family practice, geriatrics, internal medicine, neurology, neurosurgery, or psychiatry). The assessment shall be in writing and shall include the following areas: 1. Cognitive functions (e.g., orientation, comprehension, problem-solving, attention and concentration, memory, intelligence, abstract reasoning, judgment, and insight); 2. Thought and perception (e.g., process and content); 3. Mood/affect; 4. Behavior/psychomotor; 5. Speech/language; and 6. Appearance. Evidence: The record for Resident # 4 (admit date: 8-20-24) did not contain an assessment for serious cognitive impairment. This was confirmed by staff.
Based on a review of resident records the facility failed to ensure that for residents who meet the criteria for assisted living care, by the time the comprehensive ISP
Based on a review of staff records the facility failed to ensure that each direct care staff member shall maintain current certification in first aid. Evidence: -The record for Staff # 2 (date of hire: 6-21-22) and Staff # 3 (date of hire: 10-8-24) did not contain documentation of first aid certification. This was confirmed by facility staff.
Based on a review of resident records the facility failed to ensure that written acknowledgment of the receipt of the disclosure by the resident or the resident?s legal representative shall be retained in the resident's record. Evidence: The record for Resident # 4 (admit date: 8-20-24) did not contain written acknowledgment of the receipt of the disclosure. This was confirmed by facility staff.
Based on a review of resident records the facility failed to ensure that it shall develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating. The orientation and review shall cover responsibilities for: 1. Alerting emergency personnel and sounding alarms; 2. Implementing evacuation, shelter in place, and relocation procedures; 3. Using, maintaining, and operating emergency equipment; 4. Accessing emergency medical information, equipment, and medications for residents; 5. Locating and shutting off utilities; and 6. Utilizing community support services. Evidence: The facility was unable to provide documentation of a semi-annual review on the emergency preparedness and response plan for all staff. This was confirmed by facility staff.
Based on a review of staff records the facility failed to ensure that all staff shall be trained in the relevant laws, regulations, and the facility's policies and procedures sufficiently to implement: 1. Emergency and disaster plans for the facility; 2. Procedures for the handling of resident emergencies; 3. Use of the first aid kit and knowledge of its location; 4. Handwashing techniques, standard precautions, infection risk-reduction behavior, and other infection control measures specified in 22VAC40-73- 100; 5. Confidential treatment of personal information; 6. Requirements regarding the rights and responsibilities of residents; 7. Requirements and procedures for detecting and reporting suspected abuse, neglect, or exploitation of residents and for mandated reporters, the consequences for failing to make a required report, as set out in ? 63.2- 1606 of the Code of Virginia; 8. Procedures for reporting and documenting incidents as required in 22VAC40-73- 70; 9. Methods of alleviating common adjustment problems that may occur when a resident moves from one residential environment to another; and 10. For direct care staff, the needs, preferences, and routines of the residents for whom they will provide care. Evidence: The record for Staff # 2 (date of hire: 6-21-22) contained initial orientation and training that did not address all required topics. This was confirmed by facility staff.
Based on a review of resident records the facility failed to ensure that the individualized service plan ( ISP
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: 4-15-25 from 10:35 a.m.-11:25 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 51 Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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 Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Based on a self-report received from the facility and a review of the resident?s record the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. Evidence: -The record for Resident # 1 contained charting notes that documented that the resident had a fall on 8-19-24 and went to the emergency room where she received staples in her scalp and returned to the facility. -The record for Resident # 1 contained a physician?s order dated 8-20-24 that stated, ?Remove staples from posterior scalp, 8-26-24.? -According to the self-report received from the facility, ?the physician?s order was filed in the resident?s paper chart but was not entered into the electronic record.? -Charting notes dated 10-29-24 for Resident # 1 documented that upon assessment by staff, about six staples were noted on the left side back of the resident?s head. Charting notes dated 10-30-24 documented that the staples were removed from the resident?s left posterior scalp on 10-30-24 by the Nurse Practitioner.
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: 12-10-24 from 9:47 a.m.- 2:35 p.m. and 12-12-24 from 10:41 a.m.- 3:10 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: 51 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of interviews conducted with residents: 2 Number of staff records reviewed: 3 Number of interviews conducted with staff: 3 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection: facility documentation, facility postings, first aid kit, medication pass, physician?s orders, medication administration records, lunch meal/menu. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Based on a review of resident records the facility failed to ensure that the individualized service plan ( ISP
Based on a review of resident records the facility failed to ensure that the Uniform Assessment Instrument ( UAI
Based on a review of staff records the facility failed to ensure that in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. EXCEPTION: Direct care staff who are licensed health care professionals or certified nurse aides (CNA) shall attend at least 12 hours of annual training. Evidence: The record for Staff # 3 (date of hire: 1-3-23), who is a CNA, did not contain documentation of annual training. This was confirmed by facility staff.
Based on a review of resident records the facility failed to ensure that prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval of one of the following persons, in the following order of priority: 1. The resident, if capable of making an informed decision; 2. A guardian or other legal representative for the resident if one has been appointed; 3. A relative who is willing and able to take responsibility to act as the resident's representative, in the following specified order: (i) spouse, (ii) adult child, (iii) parent, (iv) adult sibling, (v) adult grandchild, (vi) adult niece or nephew, (vii) aunt or uncle; or 4. If the resident is not capable of making an informed decision and a guardian, legal representative, or relative is unavailable, an independent physician who is skilled and knowledgeable in the diagnosis and treatment of dementia. Evidence: The record Resident # 3, who resides on the secure unit, did not contain written approval of placement in a secure environment. This was confirmed by facility staff.
Based on a review of resident records the facility failed to ensure that it shall ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall document in the resident's record that this was ascertained and the date the information was obtained. Evidence: The record for Resident # 1 (admit date: 11-25-24) did not contain a sex offender screening. This was confirmed by facility staff.
Based on a review of resident records the facility failed to ensure that within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: 1. The person's name, address, and telephone number; 2. The date of the physical examination; 3. Height, weight, and blood pressure; 4. Significant medical history; 5. General physical condition, including a systems review as is medically indicated; 6. Any diagnosis or significant problems; 7. Any known allergies and description of the person's reactions; 8. Any recommendations for care including medication, diet, and therapy; 9. Results of a risk assessment documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it; 10. A statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H; 11. A statement that specifies whether the individual is considered to be ambulatory or nonambulatory as defined in this chapter; 12. A statement that specifies whether the individual is or is not capable of self- administering medication; and 13. The signature of the examining physician or his designee. Evidence: The record for Resident # 2 contained a Report of Physical Examination dated 10-15-24 that did not include all of the required items. This was confirmed by facility staff.
Based on a review of resident records the facility failed to ensure that written acknowledgment of the receipt of the disclosure by the resident or the resident?s legal representative shall be retained in the resident's record. Evidence: The record for Resident # 1 (admit date: 11-25-24) and Resident # 2 (admit date: 10-30-24) did not contain written acknowledgment of the receipt of the disclosure. This was confirmed by facility staff.
Based on a review a review of resident records the facility failed to ensure that prior to his/her admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: The record for Resident # 3, who resides on the secure unit (admit date: 1-20-23) did not contain an assessment for serious cognitive impairment. This was confirmed by facility staff.
Based on a review of resident and staff records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual and each staff person. Evidence of this review shall be the resident's, his legal representative's or responsible individual's, or staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record. Evidence: -2 of 3 staff records did not contain a written acknowledgment of a review of the rights and responsibilities of residents in assisted living facilities. -4 of 6 resident records did not contain a written acknowledgment of a review of the rights and responsibilities of residents in assisted living facilities. This was confirmed by facility staff.
Based on a review of resident records the facility failed to ensure that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident's continued residence in the special care unit. Evidence: The record for Resident # 3, who resides on the secure unit, did not contain a review of the appropriateness of the resident's continued residence in the special care unit. This was confirmed by facility staff.
Based on a review of resident records the facility failed to ensure that a copy of the written discharge statement shall be retained in the resident's record. Evidence: The record for Resident # 6 (discharge date: 10-8-24) did not contain a written discharge statement. This was confirmed by facility staff.
Based on a review of resident records the facility failed to ensure that upon admission, the assisted living facility shall provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record. Evidence: The record for Resident # 1 (admit date:11-25-24) and Resident # 2 (admit date: 10-30-24) did not contain acknowledgment of having received the orientation. This was confirmed by facility staff.
Based on a review of staff records the facility failed to ensure that each direct care staff member shall maintain current certification in first aid. Evidence: The record for Staff # 3 (date of hire: 1-3-23) did not contain documentation of first aid certification. This was confirmed by facility staff.
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7-3-24 from 9:40 a.m.-2:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 6-4-24 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 52 Number of resident records reviewed: 1 Number of interviews conducted with staff: 4 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. 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 Kimberly Davis, Licensing Inspector at (804) 662-x or by email at Kimberly.M.Davis@dss.virginia.gov
Based on a review of the resident?s record the facility failed to ensure that the fall risk rating shall be reviewed and updated under each of the following circumstances: 1. At least annually; 2. When the condition of the resident changes; and 3. After a fall. Evidence: The record for Resident # 1 contained charting notes that documented that the resident had two falls on 5-12-24 and one fall on 5-11-24. However, the resident?s record contained only one fall risk evaluation, dated 5-11-24.
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6-14-24 from 10:55 a.m.- 11:30 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 45 Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 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 Kimberly Davis, Licensing Inspector at (804) 662-757 or by email at Kimberly.M.Davis@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: 3-1-24 from 10:00 a.m.-11:10 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Additional Comments/Discussion: An unannounced monitoring inspection was conducted by licensing staff on 3-1-24 to observe the facility?s memory care unit renovations. A tour was completed and measurements were taken. The facility is not requesting an increase in its licensed capacity. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@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: 1-11-24 from 10:20 a.m.-11:40 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 12-8-23 regarding allegations in the area(s) of : resident care. Number of residents present at the facility at the beginning of the inspection: 53 Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: The identified resident was observed participating in a memory care activity. An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
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: 8-10-23 from 11:35 a.m.- 4:15 p.m. and 8-15-23 from 9:35 a.m.- 2:55 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: 54 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 5 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection: facility documentation, facility postings, first aid kit, physician?s orders, medication administration records, med pass, emergency food and water. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Based on a review of staff records the facility failed to ensure that all staff shall be trained in the relevant laws, regulations, and the facility's policies and procedures sufficiently to implement: 1. Emergency and disaster plans for the facility; 2. Procedures for the handling of resident emergencies; 3. Use of the first aid kit and knowledge of its location; 4. Handwashing techniques, standard precautions, infection risk-reduction behavior, and other infection control measures specified in 22VAC40-73-100; 5. Confidential treatment of personal information; 6. Requirements regarding the rights and responsibilities of residents; 7. Requirements and procedures for detecting and reporting suspected abuse, neglect, or exploitation of residents and for mandated reporters, the consequences for failing to make a required report, as set out in ? 63.2-1606 of the Code of Virginia; 8. Procedures for reporting and documenting incidents as required in 22VAC40-73- 70; 9. Methods of alleviating common adjustment problems that may occur when a resident moves from one residential environment to another; and 10.For direct care staff, the needs, preferences, and routines of the residents for whom they will provide care. Evidence: 4 of 4 staff records reviewed did not contain documentation that included all of the required items for initial staff training.
Based on a review of staff records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each staff person. Evidence of this review shall be the staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the staff person's record. Evidence: The record for Staff # 4 (date of hire:10-8-2001) did not contain acknowledgment of an annual review of the rights and responsibilities of residents in assisted living facilities.
Based on a review of staff records the facility failed to ensure that each direct care staff member shall maintain current certification in first aid. Evidence: The record for Staff # 4 did not contain documentation of first aid certification.
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