VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Fairview Home
5140 Hatcher Road
Dublin, VA 24084
(540) 674-5260

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: May 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

50-A, 250-D

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/11/2022 09:30 AM ? 3:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (iv) do not include any names or confidential information, and (v) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at (540)-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to include allergies and description of reactions on the physical examination preceding admission to the assisted living facility. EVIDENCE: 1. Resident 7 has a pre-admission physical examination dated 09/23/2021. 2. Penicillin was documented as an allergy; however, there were no reactions listed.
Plan of Correction:	Administrator or Designee completing admissions will ensure that physical examinations are complete with the description of the reaction to allergies prior to admission.
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to ensure the physician's or other prescriber's order included all necessary components. EVIDENCE: 1. Resident 9 was prescribed oxygen 2 Liters via nasal cannula at bedtime starting on 04/18/2014. The order did not contain the source of oxygen such as compressed gas or concentrator.
Plan of Correction:	Administrator will remind all Medication Administration staff that oxygen orders must include the oxygen source. Staff completing Quality Assurance checks will monitor for compliance.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee. EVIDENCE: The record for staff 5 indicated a date of hire of 06/14/2021; however, the criminal record report on file was dated 04/18/2022.
Plan of Correction:	Administrator will ensure criminal record reports are on record prior to the 30th day of employment.