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: March 9, 2022 and March 11, 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 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 monitoring inspection was initiated on March 9, 2022 by the licensing inspector. A census of 6 residents was reported. A follow-up visit was conducted on March 11, 2022 to complete the inspection. A sample of 4 resident and 3 staff records were reviewed. The following items were reviewed/observed: facility postings, the lunch meal, facility documentation, tour of the facility, emergency food and water supplies, medication pass, 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 #:	22VAC40-73-250-C
Description:	Based on a review of staff records the facility failed to ensure that each staff record contained the name and telephone number of a person to contact in an emergency. Evidence: The record for Staff # 3 (date of hire: 5-1-08) did not contain the name and telephone number of an emergency contact. The administrator attempted to locate the information in the record but was unable to locate it.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records the facility failed to ensure that each staff person shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: -The record for Staff # 1 (date of hire: 5-1-08) did not contain a current annual TB risk assessment. The administrator stated that she thought Staff # 1 had recently obtained a TB assessment. -The administrator attempted to locate the document but was unable to provide it.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records, the facility failed to ensure that all staff maintain current certification in first aid. Evidence: The record for Staff # 3 contained documentation of current CPR certification, but did not contain documentation of current first aid certification. Staff # 3 stated that she did not keep a copy of her last first aid certification card since it expired and that first aid was included in her most recent CPR class. The most recent CPR card did not indicate that First Aid training was also provided.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-400
Description:	Based on a review of resident records the facility failed to ensure that it provided to each resident or the resident's legal representative, if one has been appointed, a monthly statement that itemizes any charges made by the facility and any payments received from the resident or on behalf of the resident during the previous calendar month and shall show the balance due or any credits for overpayment. Evidence: The record for Resident # 1, # 2, #, 3, and # 4 did not contain a monthly statement of charges and payments. The administrator stated that the facility keeps a copy of payments received but has not been providing monthly statements.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-430-H-1
Description:	Based on a review of resident records the facility failed to ensure that a discharge statement was included in the resident's record. Evidence: The record for Resident # 1 (date of discharge 11-30-21) did not contain a discharge statement and the administrator was unable to provide the document.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 description of all needs/services identified on the Uniform Assessment Instrument (UAI). Evidence: -The ISP dated 8-1-21 for Resident # 3 (date of admission: 8-1-21) only addresses the following needs/services: Case management, day support, money management, and transportation. However, the UAI dated 7-1-21 identifies the following needs/services that were not addressed on the ISP: Cognitive function- disoriented some spheres, some of the time with short-term memory loss and judgement problems, meal preparation, housekeeping, laundry, shopping, using phone, and home maintenance. -The ISP also failed to contain a statement that specifies whether the resident does or does not need to have a staff member awake and on duty at night for a facility licensed for residential living care only, if a resident lives in a building housing 19 or fewer residents. The box for "Yes" or "No" was not checked by the statement on the ISP.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-E
Description:	Based on a review of resident records the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: -The ISP dated 8-1-21 for Resident # 3 (date of admission: 8-1-21) was not signed or dated by the resident or the resident's legal representative.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on are review of resident records the facility failed to ensure that individualized service plans (ISPs) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: The ISP for Resident # 2 (date of admission: 5-12-16) was last dated 1-4-21.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-520-I
Description:	Based on a tour of the facility the facility failed to ensure that the current month's activity schedule was posted. Evidence: The facility's activity calendar was written on a dry erase board that was dated for the month of November 2021. Photograph evidence was taken.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of staff records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident and each staff person as evidenced by the resident's or staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record. Evidence: -The record for Staff #1 did not contain documentation that included signature and date of annual review of the rights and responsibilities of residents in assisted living facilities. -The record for Staff # 2 contained an annual review of the rights and responsibilities of residents in assisted living facilities last dated 1-25-2020. -The record for Staff # 3 contained an annual review of the rights and responsibilities of residents in assisted living facilities last dated 1-27-19. -The administrator attempted to locate more recent documents but was unable to provide them.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-610-B
Description:	Based on a tour of the facility, the facility failed to have a menu for the current week dated and posted. Evidence: The facility did not have a menu posted and did not have a menu available for the inspector to review.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-E
Description:	Based on a tour of the facility the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. Evidence: The shower curtain liner in Bathroom # 1 downstairs was dirty/soiled. Photograph evidence was taken.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-950-F
Description:	Based on a review of facility documentation the facility failed to ensure that it reviewed the emergency preparedness plan semi-annually with residents and staff. Evidence: The facility's review of the emergency preparedness plan was last dated 1-26-19.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-990-C
Description:	Based on a review of facility documentation the facility failed to ensure that at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Evidence: The facility could not provide documentation of a practice exercise for a resident emergency within the past six months. However, after the inspection Staff # 3 notified the inspector by telephone that the last date of a practice exercise for a resident emergency was 11-30-2020.
Plan of Correction:	Not available online. Contact Inspector for more information.