VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Clara's East Assisted Living Facility
800 West Nine Mile Road
Highland springs, VA 23075
(804) 737-7670

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: Feb. 18, 2022 and Feb. 24, 2022

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:

An unannounced renewal inspection was initiated by the Licensing Inspector on February 18, 2022. A census of 7 residents was reported. A sample of 4 resident records and 3 staff records were reviewed. A tour of the facility was conducted, facility documentation was reviewed and facility postings were observed. The inspection was concluded on February 24, 2022 with the observation of a medication pass and the review of physician's orders and Medication Administration Records (MARs). The violations cited are identified in this report. 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 #:	22VAC40-73-440-A
Description:	Based on a review of resident records the facility failed to ensure that each Uniform Assessment Instrument (UAI) was completed at least annually. Evidence: The UAI for Resident # 2 (date of admission:7-30-2020) was dated 7-8-2020.
Plan of Correction:	The Administrator will ensure that the assessor is contacted two months prior to complete UAI by its due date.
Standard #:	22VAC40-73-860-D
Description:	Based on observation a door failed to close effectively. Evidence: The door leading to the back deck would not close properly, would re-open and required several attempts before closing.
Plan of Correction:	The Administrator will ensure by monitoring doors monthly to make sure they are operable.
Standard #:	22VAC40-73-940-A
Description:	Based on a review of facility documentation the facility failed to ensure that an annual fire inspection was conducted by the appropriate fire official. Evidence: The facility's most recent fire inspection was dated 1-21-2021.
Plan of Correction:	The Administrator will contact fire marshall in a timely manner to ensure fire inspection is conducted annually.