VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: Aug. 4, 2021 and Aug. 6, 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:

A renewal inspection was initiated on August 4, 2021 and concluded on August 6, 2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 7. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of 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. The inspector conducted the on-site portion of the inspection on August 6, 2021, which included a tour of the facility and the observance of resident rooms, facility postings, building and grounds, emergency food/water, and the medication cart. An exit interview was conducted with the administrator on the date of the inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. 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 #:	22VAC40-73-210-E
Description:	Based on a review of staff records, the facility failed to ensure that training is provided by a qualified individual through in-service training programs or institutes, workshops, classes, or conferences. Evidence: The record of training for Staff # 1 and Staff # 2 contained documentation of Trainer/Educator (Person, Agency, Organization) as "Google CNN" and "ABC News" for multiple trainings and did not include trainings provided by a qualified individual through in-service training programs or institutes, workshops, classes, or conferences.
Plan of Correction:	Administrator will only send staff to credible classes/workshops approved by VDSS.
Standard #:	22VAC40-73-920-D
Description:	Based on a tour of the facility, the facility failed to ensure that grab bars were installed by each toilet. Evidence: There was no grab bar by the toilet in the upstairs bathroom.
Plan of Correction:	Administrator had maintenance to put grab bar in the restroom.
Standard #:	22VAC40-73-980-H
Description:	Based on a tour of the facility, the facility failed to ensure that there was an availability of at least 48 hours of emergency drinking water. Evidence: There was no supply of emergency drinking water upon observation by the Licensing Inspector. The administrator stated that she had to "get more water".
Plan of Correction:	Administrator replaced 10 gallons of water and put in shed while inspector was still on-site.
Standard #:	22VAC40-80-120-E-2
Description:	Based on a tour of the facility, the facility failed to ensure that the most recently issued violation notice was posted. Evidence: The most recently issued violation notice was not posted in the facility.
Plan of Correction:	Administrator will post recent violation notice.