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Anthology of Charlottesville
343 Archer Avenue
Charlottesville, VA 22911
(434) 218-5035

Current Inspector: Tamara Watkins (804) 662-7422

Inspection Date: July 12, 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:
A renewal inspection was completed on 7/12/2022 from 12:05p ? 3:00p. Two licensing representatives were on site during the inspection. The Administrator and Director of Health and Wellness participated in the inspection. The census on the day of the inspection was 47 residents. Six (6) resident and six (6) staff files were reviewed for compliance, along with medication administration, required postings, fire and health inspections, medication administration, required postings, fire and health inspections, facility maintenance and repair, etc.
The Acknowledgement of Inspection form was signed and left at the facility.

The evidence gathered during the initial inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. 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 a licensed facility.

For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov

Should you have any questions, please contact Tamara Watkins, Licensing Inspector at (804) 662-7422 or by email at tamara.g.watkins@dss.virginia.gov

Violations:
Standard #: 22VAC40-73-1090-A
Description: Based on a review of resident files the facility failed to ensure that prior to admission in a safe, secure environment that residents are assessed as having a serious cognitive impairment due to a primary diagnosis of dementia with an inability to recognize danger or protect his own safety or welfare.
Evidence:
There was no assessment maintained in the file or available for verification for resident #6 who has resided in the memory care unit since 3/7/22.

Plan of Correction: Approval for placement will
be added to chart audit sheet.
Residents being admitted to
memory care will not be
admitted unless approval and
assessment are completed.
Audit tool will be completed
for each new resident being
admitted to memory care unit.

Standard #: 22VAC40-73-1100-A
Description: Based on a review of resident records the facility failed to obtain written approval prior to placing a resident with a serious cognitive impairment in a safe, secure environment.
Evidence:
Resident # 6 was placed in the secure memory care unit on 3/7/2022 without the written approval of their guardian or representative based on the order of priority. There was no documentation in the resident?s file that approval was obtained.

Plan of Correction: Approval for placement will
be added to chart audit sheet.
Residents being admitted to
memory care will not be
admitted unless approval and
assessment are completed.
Audit tool will be completed
for each new resident being
admitted to memory care unit.

Standard #: 22VAC40-73-120-A
Description: Based in a review of staff records the facility failed to ensure that staff orientation and training occurred within the first seven days of employment.
Evidence:
Staff #1 was employed on 6/29/22 and did not have written documentation of orientation and training in the staff file.

Plan of Correction: Process put in place:
Each resident and staff record
will be audited to assure
compliance and completion of
Orientation documentation.
Audit tool will be completed
for each new record upon new
hire or admission.

Standard #: 22VAC40-73-250-D
Description: Based on a review of staff files the facility failed to complete initial tuberculosis screenings for staff on or within seven days prior to the first day of work at the facility.
Evidence:
Staff #1 began working at the facility on 6/29/22 and staff #5 began working on 12/6/21. A risk assessment or TB screening was not documented/maintained in the staff file.

Plan of Correction: Process put in place:
Each resident and staff record
will be audited to assure
compliance and completion of
TB screening. Audit tool will
be completed for each new
record upon new hire or
admission.

Standard #: 22VAC40-73-720-A
Description: Based on a review of resident files the facility failed to include Do Not Resuscitate Orders in residents individualized service plans.
Evidence:
Three residents (residents #2, 3, 4) with DNR orders did not have them included in their individualized service plans.

Plan of Correction: DNR status will be added to
print off of care plan which is
signed by resident or family
member, status will be printed
on first page of care plan.
DNR status will noted on back
of chart with red dot.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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