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: Jan. 13, 2021 and Jan. 14, 2021

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 renewal inspection was initiated on January 13, 2021 and concluded on January 14, 2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 5. The inspector emailed the administrator a list of items required to complete the inspection. The administrator reported that the current census was 5. 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 a violation was documented on the violation notice issued to the facility. Please complete the "plan of correction" and "date to be corrected" for the 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 #:	22VAC40-73-650-E
Description:	Based on a review of resident records and a phone conversation with the administrator, the facility failed to ensure that each resident's record contained the physician's or other prescriber's signed written order. Evidence: Record for Resident # 1 (date of admission: 4-22-19) did not contain a physician's order. The Administrator informed the Licensing Inspector that the facility did not have the physician's order for the two medications that are administered to resident and had contacted the resident's physician to obtain the order.
Plan of Correction:	Administrator/designee will ensure all prescibers provide facility with physician orders.