VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Babcock Manor, Inc.
State Route 691
Appomattox, VA 24522
(434) 352-8686

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: June 21, 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 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 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/21/2022 9:30am until 2:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 25 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on a review of resident records, the facility failed to ensure that the statement prepared and provided to the prospective resident and his legal representative, if any, that discloses information about the facility included all required components. EVIDENCE: 1. The record for resident 2, admitted on 04/29/2022 and resident 3, admitted on 11/15/2022 had a ?Assisted Living Facility Disclosure Statement? that did not include a statement of whether or not the facility has an on-site emergency electrical power source for the provision of electricity during an interruption of the normal electric power supply.
Plan of Correction:	The Administrator will print off the new Disclosure Statement form from the DSS website and will begin using it.
Standard #:	22VAC40-73-270-4
Description:	Based on a review of staff records, the facility failed to ensure all staff received annual training in methods of dealing with residents who have a history of aggressive behaviors or dangerously agitated states. EVIDENCE: 1. The record for staff person 2, hired on 01/15/2020 and staff person 3, hired in 4/1989 have documentation that the last training for aggressive behaviors was conducted in 2020.
Plan of Correction:	The Administrator will schedule a training in aggressive behaviors for all direct care staff.
Standard #:	22VAC40-73-350-B
Description:	Based on a review of resident records, the facility failed to ascertain prior to admission whether a potential resident was a registered sex offender. EVIDENCE: 1. The record for resident 2, admitted on 04/29/2022 has documentation that a sex offender screening was not admitted until 05/03/2022. 2. The record for resident 3, admitted on 11/15/2022 has a sex offender screening that does not have a date of completion.
Plan of Correction:	The Administrator will ensure that all new admissions receive a sex offender screening prior to their admission.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of resident records, the facility failed to ensure that all identified needs were reflected on resident individualized service plans (ISPs). EVIDENCE: 1. The record for resident 1 has documentation that the resident is receiving mental health services. The ISP dated 04/01/2022 does not reflect this identified need. 2. The record for resident 2 has documentation that the resident is receiving mental health services. The uniform assessment instrument (UAI) dated 12/14/2021 in the record for resident 2 has documentation that the resident is disoriented some spheres some of the time with time and situation being the spheres affected and that the residents behavior pattern is abusive/aggressive/disruptive less than weekly. The ISP dated 04/29/2022 in the record for resident 2 does not reflect these identified needs. 3. The record for resident 3 has a fall risk dated 11/15/2021 that rates that resident at an increased risk for falls. The UAI dated 11/11/2021 in the record for resident 3 has that the resident is disoriented to all spheres some of the time. The ISP dated 11/15/2021 for resident 3 does not reflect these identified needs.
Plan of Correction:	The Administrator will review these ISP?s and will update to reflect all identified needs.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of staff records, the facility failed to ensure annual training on resident rights and responsibilities with all staff. EVIDENCE: 1. The records for staff persons 2 and 3 have documentation that the last training in resident rights and responsibilities was completed on 12/15/2020.
Plan of Correction:	The Administrator will schedule an annual review of resident rights will all staff.
Standard #:	22VAC40-73-560-I
Description:	Based on a review of resident records, the facility failed to ensure that a current resident photo was available for identification purposes. EVIDENCE: 1. The record for resident 2, admitted on 04/29/2022 did not contain a current photo on the day of inspection.
Plan of Correction:	The Administrator will ensure a current photo for all residents are obtained
Standard #:	22VAC40-73-610-D
Description:	Based on a review of resident records and interview with staff, the facility failed to ensure that special diets prescribed to residents were prepared and served according to physician instructions. EVIDENCE: 1. The record for resident 2 has documentation of a controlled carbohydrate diet. The record for resident 4 has documentation that the resident is on a regular soft food diet. 2. On the day of inspection it was observed that a special diet list was not available in the facility kitchen. Interview with staff person 1, who was preparing the lunch meal, expressed that there are currently no special diets and that all residents receive the same diet/food.
Plan of Correction:	The Administrator will ensure that a diet list for all residents who are on a special diet is kept current in the facility kitchen. The Administrator will in-service all staff on the diet list location.
Standard #:	22VAC40-73-700-2
Description:	Based on observations of the facility physical plant, the facility failed to post a ?No Smoking-Oxygen in Use? sign at all rooms where oxygen is in use. EVIDENCE: 1. Room 9 upstairs was noted to have an oxygen concentrator sitting by the first bed in the room. The room did not have a ?No Smoking ?Oxygen in Use? sign posted.
Plan of Correction:	A No Smoking sign will be posted on room 9.
Standard #:	22VAC40-73-980-A
Description:	Based on observations of the facility first aid kit, the facility failed to ensure that expiration dates have not passed on items inside the kit. EVIDENCE: 1. The facility first aid kit was noted to have a bottle of Betadine with an expiration date of 12/2020.
Plan of Correction:	The Betadine was removed from the first aid kit and expiration dates will be checked monthly.