VIRGINIA DEPARTMENT OF SOCIAL SERVICES

RAH Winthrop Manor
2100 Idlewood Avenue
Richmond, VA 23220
(804) 278-8982

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: March 17, 2023

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

Comments:

Type of inspection: Monitoring Date and time the licensing inspector was on-site at the facility for each day of the inspection: 3-17-2023 9a-12:15 p 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. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Lunch meal, medication administration, postings, physical plant Additional Comments/Discussion: 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 Yvonne Randolph, Licensing Inspector at (804) 662-7454 or by email at yvonne.randolph@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-A
Description:	Based on a review of five staff files, the facility did not ensure that direct care staff attend at least 14 hours of training annually. Evidence: Fourteen hours of annual training was not documented for staff # 1, # 2 and # 5.
Plan of Correction:	The Administrator will ensure that the required training will be provided as per 210.A Standard.
Standard #:	22VAC40-73-320-A
Description:	Base on a review of ten resident files, a physical examination by an independent physician was not completed within 30 days preceding admission for one resident. Evidence: 1. A physical examination was not in the file for resident #1, # 4, # 6 or # 7. 2. The physical for resident # 3 was completed more than 30 days prior to admission. 3. The physical for resident # 2 was completed after admission.
Plan of Correction:	The Administrator will ensure that physical examination will be completed within 30 days prior to admission.
Standard #:	22VAC40-73-320-B
Description:	Based on a review of ten resident files, the facility did not ensure the annual completion of a risk assessment for tuberculosis for each resident. Evidence: Residents # 1, # 3, # 4 and # 7 did not have an annual risk assessment for tuberculosis.
Plan of Correction:	The Administrator will ensure that annual risk assessments are completed annually as per 320.B.1