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: Jan. 13, 2022 and Jan. 14, 2022

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 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:

An unannounced renewal inspection was initiated by licensing staff on January 13, 2022 from 9:35 a.m. to 2:00 p.m. A census of 16 residents was reported. A sample of 6 resident records and 3 staff records were reviewed as well as other facility documentation. A follow-up visit was conducted by licensing staff on January 14, 2022 from 2:00 p.m. to 3:15 p.m. to complete the renewal inspection with a tour of the facility, observation of emergency food and water supply and a medication pass, as well as review of physician's orders/Medication Administration Records (MARs). The violations cited are identified in this report. 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 #:	22VAC40-73-120-A
Description:	Based on a review of staff records, the facility failed to ensure that staff orientation and initial training occurred within the first seven working days of employment. Evidence: The record for Staff # 1 (date of hire: 5-29-17) did not contain documentation of staff orientation and initial training. Staff # 4 stated that orientation and training had been completed for Staff # 1 but not documented.
Plan of Correction:	The administrator will ensure that all initial training and orientation will occur within the first seven days of employment.
Standard #:	22VAC40-73-210-G
Description:	Based on a review of staff records the facility failed to ensure that it documented the type of training, the entity that provided the training, number of hours of training, and dates of the training and shall be kept by the facility in a manner that allows for identification by individual staff person and is considered part of the staff member's record. Evidence: The record for Staff # 1 (date of hire: 5-29-17) did not contain documentation of any training hours. Staff # 4 stated that Staff # 1 had completed training hours, but the facility failed to document the training hours.
Plan of Correction:	The administrator will ensure that hours, dates, type, and person who provided the training will be documented.
Standard #:	22VAC40-73-250-C
Description:	Based on a review of staff records the facility failed to ensure that each staff record contained the required personal and social data. Evidence: -The record for Staff # 1 (date of hire: 5-29-17) did not contain the following personal and social data: verification that the staff person had received a copy of his/her current job description, name and number of person to contact in an emergency, an original criminal record report and a sworn disclosure statement. -The record for Staff # 3 did not contain the following personal and social data: name and telephone number of person to contact in an emergency.
Plan of Correction:	The administrator will ensure that all staff records contain all personal and social data.
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records the facility failed to ensure that each staff person submit the results of a tuberculosis (TB) risk assessment on or within seven days prior to the first day of work at the facility and that each staff person submit the results of a risk assessment annually. Evidence: -The record for Staff # 3 (date of hire: 10-7-21) did not contain an initial TB risk assessment. -The record for Staff # 1 (date of hire: 5-29-17) contained a TB screening last dated 3-18-17. -Staff # 4 stated that current TB screenings had not been obtained for Staff # 1 and Staff # 3, but would be scheduled.
Plan of Correction:	All staff have been given a TB screening and the results will be placed in each staff record.
Standard #:	22VAC40-73-320-A
Description:	Based on a review of resident records, the facility failed to ensure that each resident had a physical examination within 30 days preceding admission and that the physical examination report contained the date. Evidence: -The physical examination report for Resident #2 (admit date: 3-9-17) was not dated to reflect that it was completed within 30 days preceding admission. -The physical examination report for Resident # 3 (admit date: 12-2-21) was dated 10-1-2020.
Plan of Correction:	The administrator will ensure that each resident will have a physical examination 30 days prior to admission.
Standard #:	22VAC40-73-320-B
Description:	Based on a review of resident records, the facility failed to ensure that a risk assessment for tuberculosis was completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: -The record for Resident # 3 contained a TB screening last dated 10-1-2020. The record for Resident # 5 contained a TB screening last dated 3-8-17.
Plan of Correction:	The administrator will ensure that all TB screenings for residents will be completed annually.
Standard #:	22VAC40-73-350-B
Description:	Based on a review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the date the information was obtained. Evidence: The record for Resident # 3 (admit date: 12-2-21) did not contain documentation of a sex offender registry search. Staff # 4 stated that the facility was waiting to receive the results of the sex offender search for Resident # 3 that the facility requested.
Plan of Correction:	The administrator will ensure that all sex offender registry searches will be obtained prior to admission.
Standard #:	22VAC40-90-30-B
Description:	Based on a review of staff records the facility failed to ensure that the sworn statement or affirmation was completed for all applicants for employment. Evidence: -The record for Staff # 1 and Staff # 3 did not contain a sworn statement or affirmation. Staff # 4 stated that the facility had not requested sworn statement or affirmation forms for Staff # 1 and Staff # 3 upon employment.
Plan of Correction:	The administrator will ensure that a sworn disclosure statement or affirmation is completed for all applicants/staff.
Standard #:	22VAC40-90-40-B
Description:	Based on a review of staff records, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: The record for Staff #1 (date of hire: 5-29-17) did not contain documentation of a criminal history record report. Staff # 4 stated that facility had not obtained a criminal history report for Staff # 1.
Plan of Correction:	Administrator will ensure that all criminal history record reports will be obtained prior to the 30th day of employment.