VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Coles' Retirement Home, Inc.
800 North Boulevard
Richmond, VA 23220
(804) 355-2741

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: March 11, 2021 and March 16, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on March 11, 2021 and concluded on March 16, 2021 with a virtual tour of the facility. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 17. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 2 resident records, 2 staff records, physician's orders, Medication Administration Records, and other documentation submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it to the licensing office within 10 calendar days. Please specify how the violation will be corrected. The plan must contain: 1) step(s) to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation during this inspection. I can be reached at Kimberly.M.Davis@dss.virginia.gov or (804) 662-7578.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that each resident's individualized service plan (ISP) contained a written description of all identified needs. Evidence: The Uniform Assessment Instrument (UAI) for Resident # 1 (last dated 1-7-2020) indicated that the resident needs help with the following : bathing, dressing, bladder incontinence, laundry, shopping, using the phone, and home maintence. However, the resident's ISP (last dated 1-8-2020) does not address those needs and only addresses meal preparation, housekeeping, money management, transportation, medication administration, and mental health.
Plan of Correction:	The administrator will ensure that all needs listed on the UAI are addressed on the ISP.
Standard #:	22VAC40-73-750-B
Description:	Based on a virtual tour of the facility, the facility failed to ensure that each bedroom contained a mirror. Evidence: Room # 3 on the second floor did not contain a mirror.
Plan of Correction:	A mirror was placed in Room # 3.
Standard #:	22VAC40-73-920-D
Description:	Based on a virtual tour of the facility, the facility failed to ensure that grab bars were installed by each toilet. Evidence: Bathroom #1 and Bathroom # 2 did not have a grab bar by the toilet.
Plan of Correction:	Grab bars have been installed in bathroom # 1 and # 2.