VIRGINIA DEPARTMENT OF SOCIAL SERVICES

DLM Corporation
3502 Chamberlayne Avenue
Richmond, VA 23227
(804) 357-6743

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: Sept. 21, 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

Technical Assistance:

A review of facility records and physician orders revealed that one resident is diagnosed with end stage renal disease. Although a special diet was not noted during the file, a dietary evaluation is indicated. Please consider having the resident evaluated for nutritional needs.

Comments:

A monitoring inspection was initiated on 9/14/21 and concluded on 9/21/21. The (person in charge) was contacted by telephone to initiate the inspection. The administrator reported that the current census was 21 residents. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed three resident records, three staff records, activities calendar, menu. staff schedules, required postings, medication administration records and physician order to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 9/21/21. An exit interview was conducted with the Administrator and Staff person in Charge on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, violations are documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-290-A
Description:	Based on on site observation at the facility on 9/21/2021, the facility failed to maintain a posted schedule with an indication of whomever is in charge at any given time. Evidence: During an on-site walk through of the facility with the facility's staff (#1), licensing staff found no posting of staff in charge.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-610-B
Description:	Based on a review of the posted menu, interview with staff and an observation of the pending dinner meal, menu substitutions or additions were not recorded on the posted menu. Evidence: The dinner meal for 9/21/21 per the posted menu was pizza bites, fruit, mixed vegetables, dessert. Chips were observed by each plate on the pre-set table. The staff reported that the menu had changed to sandwiches, fruit, chips and dessert. The change was not made on the posted menu. .
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-750-B
Description:	Based on an on site observation at the facility on 9/21/2021, the bedrooms did not contain an operable bed lamp or bedside light that was accessible to each resident; Evidence: During an on-site walk through of the facility with the facility's staff (#1), licensing staff found that a bed lamp or bedside light was not accessible to each bed.
Plan of Correction:	Not available online. Contact Inspector for more information.