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Metro Gardens Assisted Living Facility
17 Shore Street
Petersburg, VA 23803
(804) 732-1813

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: March 4, 2024

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: 3-4-24 from 8:42 a.m.-12:00 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: 12
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
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Additional Comments/Discussion: The following items were also reviewed/observed during the inspection- facility documentation, facility postings, first aid kit, medication pass, physician?s orders, and medication administration records.

An exit meeting was 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

Violations:
Standard #: 22VAC40-73-50-A
Description: Based on a review of resident records the facility failed to ensure that the assisted living facility shall prepare and provide a statement to the prospective resident and his legal representative, if any, that discloses information about the facility.

Evidence:
The record for Resident # 3 (admit date: 4-28-23) did not contain a facility disclosure statement.

Plan of Correction: Administrator will ensure that the disclosure information is provided and signed by the resident.

Disclosure statement was provided and included in the resident record.

Standard #: 22VAC40-73-250-C
Description: Based on a review of staff records the facility failed to ensure that each staff record contained an original criminal record report and a sworn disclosure statement.

Evidence:
-The record for Staff # 1 (date of hire: 11-1-22) did not contain a criminal record report.
-The record for Staff # 3 (date of hire: 1-30-19) did not contain a sworn disclosure statement.

Plan of Correction: Administrator will ensure that the original criminal record report and sworn disclosure statement is in the record.

Criminal check report was submitted. Sworn disclosure was signed and put in record.

Standard #: 22VAC40-73-450-E
Description: Based on a review of resident records the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative.

Evidence:
The ISP dated 12-27-23 for Resident # 4 (admit date: 6-11-14) was not signed and dated by the resident or his legal representative.

Plan of Correction: Administrator will ensure that the ISP will be signed and dated properly.

ISP was updated and signed by the resident.

Standard #: 22VAC40-73-550-G
Description: Based on a review of resident records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual. Evidence of this review shall be the resident's, his legal representative's or responsible individual's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's record.

Evidence:
The record for Resident # 5 (admit date: 10-4-22) did not contain documentation of the annual review of the rights and responsibilities of residents in assisted living facilities.

Plan of Correction: Administrator will ensure that the annual review of the rights and responsibilities will be documented in the record.

Annual review was completed and documented in the record.





Annual review was completed and documented in the record.

Standard #: 22VAC40-73-650-E
Description: Based on observation of physician?s orders during medication pass, the facility failed to ensure that the resident's record shall contain the physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's oral order.

Evidence:
The facility did not have signed physician?s orders for two of two residents observed during medication pass.

Plan of Correction: Administrator will ensure that the prescriber's orders are signed.

Physician orders submitted for signature.

Standard #: 22VAC40-73-980-C
Description: Based on a review of the facility?s first aid kit the facility failed to ensure the first aid kits shall be checked at least monthly.

Evidence:
The facility?s last documented check of the first aid kit was dated 2-6-23.

Plan of Correction: Administrator will ensure that documentation of the first aid kit is maintained.
Started and put in kit.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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