VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Guardian Light, LLC
2101 Mountain Run Drive
Glen allen, VA 23060
(804) 261-5824

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: June 23, 2020

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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 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:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on June 22, 2020 and concluded on June 23, 2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 6. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 2 resident records, 2 staff records, physician's orders, Medication Administration Records (MARs), and other facility documentation submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-290-A
Description:	Based on a review of facility documentation, the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working each shift with an indication of whomever is in charge at any given time. Evidence: The facility submitted a staff information sheet with each staff member's work hours/shift, but not a schedule that indicates whomever is in charge.
Plan of Correction:	Administrator/Designee will ensure all required information is on the staff schedule at all times.
Standard #:	22VAC40-73-300-B
Description:	Based on a review of documentation, the facility failed to ensure that a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. Evidence: On Part 5 of the R&M 2 form the administrator answered "No" to question G. which asks " Is a method of written communication being utilized to keep direct care staff on each shift informed of significant events ?" The administrator wrote in the comments section, "Will start to use communication log, but currently we do verbal and telephone during each shift".
Plan of Correction:	Facility has begun utilizing communication log. Each staff will read and sign that they read the communication log on each shift. Staff will document any issues on shift.
Standard #:	22VAC40-73-490-A-3
Description:	Based on a review of facility documentation, the facility failed to ensure that all residents shall be included at least annually in healthcare oversight. Evidence: The last healthcare oversight for Resident # 1 was dated 1-15-19.
Plan of Correction:	Administrator will ensure all residents have healthcare oversight annually.