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: Dec. 20, 2022 and Dec. 21, 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 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:

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: 12-20-22 from 7:15 a.m. - 11:20 a.m. and 12-21-22 from 3:25 p.m.- 4:25 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: 15 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 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection: facility documentation, facility postings, first aid kit, emergency food and water, medication pass, physician?s orders, and Medication Administration Records (MARs). 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov Violation Notice Issued: Yes A copy of this document will be sent to the licensee/provider for signature.

Violations:

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 # 2 (date of hire: 5-30-17) contained a TB screening last dated 3-18-17.
Plan of Correction:	A TB Assessment was obtained on 12/28/2022 and has been placed in Staff #2 file.
Standard #:	22VAC40-73-440-A
Description:	Based on a review of resident records the facility failed to ensure that the Uniform Assessment Instrument (UAI) shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition. Evidence: The record for Resident # 6 (admit date: 2-19-14) contained a UAI that was last dated 5-24-21.
Plan of Correction:	A copy of the resident's UAI has been placed in resident's file. The assessment date is 01/10/2023.
Standard #:	22VAC40-73-610-B
Description:	Based on observation the facility failed to ensure that menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents. Evidence: The facility did not have the menu posted.
Plan of Correction:	The facility has posted the menu in the dining area.
Standard #:	22VAC40-73-870-E
Description:	Based on a tour of the facility the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. Evidence: The shower grab bar in the upstairs bathroom was rusted. Photographic evidence was taken.
Plan of Correction:	The shower grab bar has been removed and a new one installed.
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 # 2 (date of hire: 5-30-17) did not contain documentation of a criminal history record report. The administrator was unable to locate the documentation.
Plan of Correction:	A criminal history record report was requested from Virginia State Police on 12/29/2022 and upon receipt will be placed in Staff #2 file.