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Atkinson's Retirement Home
4001 Elmswell Drive
Richmond, VA 23223
(804) 236-0175

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: Oct. 6, 2020 and Oct. 7, 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
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 with follow up on previous high risk violations was initiated on October 6, 2020 and concluded on October 8, 2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 8. 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 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 #: 22VAC40-73-450-C
Description: Based on a review of resident records, the facility failed to ensure that each resident's individualized service plan (ISP) contained a written description to address all identified needs.

Evidence:
-The Virginia Uniform Assessment Instrument (UAI) for Resident # 1 (date of admission: 6-1-18) dated 5-7-2020 indicated the following identified needs that are not addressed on resident's ISP dated 7-1-2020: mechanical assistance only with ambulation, Tooth or Mouth Problems with a notation of No teeth or dentures under the question "Do you have any problems that make it hard to eat ?", Disorientation-some spheres, all of the time with the spheres affected noted as "Time" under the Cognitive Function category, and short-term and long-term memory loss under the Recall/Memory/Judgment category.
-The UAI for Resident # 2 (date of admission: 8-23-2020) dated 7-1-2020 indicated the following identified needs that are not addressed on resident's ISP dated 9-23-2020: supervision with bathing and dressing, and case management one time monthly as well as mental health (psychiatrist) one time monthly under Current Formal Services.

Plan of Correction: ISP was rewritten and every detail listed on the UAI has been added and reviewed by RN to reassure accuracy.

Standard #: 22VAC40-73-450-F
Description: Based on a review of resident records the facility failed to ensure that each resident's individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed as the condition of the resident changes.


Evidence: The comprehensive ISP for Resident # 1 (date of admission: 6-1-18) was dated 7-1-2020, however the resident's Uniform Assessment Instrument (UAI) was dated 5-7-2020.

Plan of Correction: ISP was rewritten. All needs listed on UAI are also on the ISP and will be updated every 12 months or PRN.

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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