VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Aable Rest Home
31 Stoney Point Road
Cumberland, VA 23040
(804) 492-4135

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: Aug. 18, 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 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

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: 8-18-22 10:38 a.m.- 4:00 p.m. 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: 18 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Additional Comments/Discussion: The following items were reviewed/observed during the inspection: facility documentation, facility postings, the lunch meal, tour of the facility, first aid kit, medication pass/physician?s orders/Medication Administration Records (MARs). 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov Violation Notice Issued: Yes A copy of this document will be sent to the licensee/provider for signature.

Violations:

Standard #:	22VAC40-73-120-A
Description:	Based on observation and an interview with staff the facility failed to ensure that orientation and training shall occur within the first seven working days of employment. Evidence: -The facility did not have documentation of orientation and initial training for Staff # 4 (date of hire: 8-8-22) . -Staff # 3 stated ?I thought we had 30 days.?
Plan of Correction:	Administrator will ensure that with all future staff, orientation/initial training will all be complete on the first day of employment.
Standard #:	22VAC40-73-210-F
Description:	Based on a review of staff records the facility failed to ensure that at least two hours of annual training shall focus on infection control. Evidence: The record for Staff # 2 (date of hire: 6-2-2000) did not contain documentation of two hours of annual infection control training.
Plan of Correction:	Administrator will ensure that moving every staff member will receive at least 2 hrs. of infection control training.
Standard #:	22VAC40-73-250-A
Description:	Based on an observation and an interview with staff the facility failed to ensure that a record shall be established for each staff person. Evidence: -The facility did not have a record established for Staff # 4 (date of hire: 8-8-22) that contained the following required items: name, birthdate, current address and telephone number, position title and date employed, verification that the staff person has received a copy of his/her current job description, an original criminal report and a sworn statement, name and telephone number of person to contact in an emergency, documentation of orientation and training. -Staff # 3 stated they had not created a record for Staff # 4 yet.
Plan of Correction:	Administrator will ensure moving forward that files are set up on first day of employment.
Standard #:	22VAC40-73-250-A
Description:	Based on an observation and an interview with staff the facility failed to ensure that a record shall be established for each staff person. Evidence: -The facility did not have a record established for Staff # 4 (date of hire: 8-8-22) that contained the following required items: name, birthdate, current address and telephone number, position title and date employed, verification that the staff person has received a copy of his/her current job description, an original criminal report and a sworn statement, name and telephone number of person to contact in an emergency, documentation of orientation and training. -Staff # 3 stated they had not created a record for Staff # 4 yet.
Plan of Correction:	Administrator will ensure all new employee checklists will be complete in an appropriate time.
Standard #:	22VAC40-73-250-C
Description:	Based on a review of staff records the facility failed to ensure that personal and social data be maintained on staff. Evidence: -The record for Staff # 1 (date of hire: 11-8-1995) did not contain the following required items: birthdate, current address and phone number, name and telephone number of person to contact in an emergency. -The facility did not have person and social data for Staff # 4 (date of hire: 8-8-22) as there was no record established.
Plan of Correction:	Administrator will ensure that personal and social data sheets will be included in new check list for new employee and residents.
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records the facility failed to ensure that each staff member 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 : 11-8-1995) contained a Patient PPD form that indicated a PPD test was given on 2-16-22, but did not document the results of the test. -The record for Staff # 3 (date of hire 9-1-13) did not contain a current risk assessment for tuberculosis. Staff # 3 stated that he had a current TB test completed and would contact the doctor?s office to obtain a copy. (LI did not note the date of Staff # 3?s last TB in record.) -The facility did not have an initial TB examination and report for Staff # 4 (date of hire 8-8-22).
Plan of Correction:	Administrator will put TB results in staff file as soon as they arrive in the future.
Standard #:	22VAC40-73-320-B
Description:	Based on a review of resident records the facility failed to ensure that a risk assessment for tuberculosis (TB) shall be completed annually on each resident 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 Resident # 3 (admit date: 6-8-1999) contained a TB screening last dated 2-27-2020. -The record for Resident # 4 (admit date: 4-1-16) contained a TB screening last dated 2-27-2020. -Staff # 3 stated that current TB tests had been completed for Resident # 3 and Resident # 4 but the facility did not have copies of the results. Staff # 3 stated he was contacting the doctor?s office to request copies.
Plan of Correction:	Administrator will ensure TB results are in resident files as soon as they receive them.
Standard #:	22VAC40-73-350-B
Description:	Based on a review of resident records the facility failed to ensure that it ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall document in the resident record that this was ascertained and the date the information was obtained. Evidence: -The record for the following residents did not contain a sex offender screening: Resident # 1 (admit date: 4-4-22), Resident # 2 (admit date: 6-1-22), and Resident # 3 (admit date: 6-8-99). -Regarding the sex offender screening for Resident # 1 and Resident # 2, Staff # 3 stated ,?We must have forgotten.? Regarding the screening for Resident # 3, Staff # 3 stated, ?I believe we had it. I don?t know why it?s not in the record.?
Plan of Correction:	Administrator will have sex offender checked prior to admission in the future.
Standard #:	22VAC40-73-410-A
Description:	Based on a review of resident records the facility failed to ensure that upon admission, the facility shall provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call bell system. Evidence: -The record for Resident # 1 (admit date: 4-4-22) and Resident #2 (admit date: 6-1-22) did not contain documentation of resident orientation. -Staff # 3 stated, ?If you don?t see it, it?s not in there.?
Plan of Correction:	Administrator formed a new resident check list for future new residents.
Standard #:	22VAC40-73-440-A
Description:	Based on a review of resident records the facility failed to ensure that the Uniform Assessment Instrument (UAI) shall be completed at least annually, and whenever there is a significant change in the resident?s condition. Evidence: -The record for Resident # 6 (admit date: 7-31-19) contained a UAI last dated 7-17-19. -Staff # 3 stated that the facility had has difficulty getting local assessors to complete UAIs.
Plan of Correction:	Administrator has requested UAI to be completed on multiple occasions with the most recent phone call being 9/22/22. Administrator will continue to reach out to Cumberland Social services with hopes of a return call.
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 written description of all identified needs and what services will be provided. Evidence: -The Uniform Assessment Instrument (UAI) for Resident # 2 (admit date: 6-1-22) dated 3-31-22 indicates that the resident needs help with the following activities that were not addressed on the resident?s ISP dated 6-1-22: bathing (supervision), toileting (mechanical help), transferring (mechanical help), bowel and bladder incontinence, ambulation- walking, wheeling, mobility (mechanical help) and stairclimbing (supervision). -The UAI for Resident # 4 (admit date: 4-1-16) dated 8-12-22 indicates that the resident needs help with phone use, however it is not addressed on the resident?s ISP dated 12-19-21.
Plan of Correction:	Administrator will review all ISPs and ensure they address all identified needs.
Standard #:	22VAC40-73-520-A
Description:	Based on observation of the facility?s activity schedule the facility failed to ensure that it offers residents a varied mix of weekly activities including those that are physical; social; cognitive, intellectual, or creative; productive; sensory; reflective or contemplative; involve nature or the natural world; and weather permitting, outdoor activity. Any given activity may involve more than one of these. Community resources as well as facility resources may be used to provide activities. Evidence: The facility?s activity schedule contained only the following categories of activities: Shopping in the community, Game, Educational T.V. and Nature Walk.
Plan of Correction:	Administrator has created new activity schedules that include 11 hours and a varied mix of weekly activities.
Standard #:	22VAC40-73-520-D
Description:	Based on observation of the facility?s activity schedule, the facility failed to ensure that in a facility licensed for residential living care only, there shall be at least 11 hours of scheduled activities available to the residents each week for no less than one hour each day. Evidence: The facility?s posted activity schedule indicated a maximum of 7 hours per week for activities. Photographic evidence was taken.
Plan of Correction:	Administrator has created new activity schedules that include 11 hours and a varied mix of weekly activities.
Standard #:	22VAC40-73-610-B
Description:	Based on observation the facility failed to ensure that the menus for meals and snacks for the current week shall be posted and dated in an area conspicuous to residents. Evidence: The menu, written on a dry erase board, was not for the full week and was not dated. Photographic evidence was taken.
Plan of Correction:	Administrator formed new menu template to be on display Monday morning for the week.
Standard #:	22VAC40-73-650-E
Description:	Based on a review of resident records the facility failed to ensure that the resident?s record shall contain the physician?s or other prescriber?s signed written order or a dated notation of the physician?s or other prescriber?s oral order. Orders shall be organized chronologically in the resident?s record. Evidence: -The record for Resident # 2, # 3, and # 6 did not contain signed physician?s orders. The record contained Physician?s Order sheets that were not signed. -Staff # 3 stated they will make sure they obtain the signed physician?s orders.
Plan of Correction:	Administrator will ensure current physicians order will be going to the Dr. each visit to make sure they are signed.
Standard #:	22VAC40-73-870-E
Description:	Based on observation during a tour of the facility with the administrator, the facility failed to ensure that all furnishings, fixtures, and equipment, including toilets, bathtubs, and showers, shall be kept clean and in good repair and condition, except that furnishings and equipment owned by a resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard. Evidence: Licensing inspector observed the following and photographic evidence was taken: -Rusted heating vent in Bathroom # 1 with stained flooring by vent. -Cabinet door under sink would not close in Bathroom # 1. -Stained ceiling above shower in Bathroom # 2. -Large areas of chipped paint on stairway handrail. -Soiled, stained dark areas of carpet on bottom steps of stairway.
Plan of Correction:	Painting & home maintenance is in the works and will be done in the near future.
Standard #:	22VAC40-73-950-E
Description:	Based on an interview with staff the facility failed to ensure that it shall develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, , and volunteers, with emphasis placed on an individual?s respective responsibilities. The review shall be documented by signing and dating. Evidence: -The facility did not have documentation of a semi-annual review of the emergency preparedness and response plan. Staff # 3 stated, ?We?ve reviewed it, but can?t find it?. No documentation was provided.
Plan of Correction:	Administrator created a new form to keep track of emergency preparedness and response plan training to ensure its done.
Standard #:	22VAC40-73-960-B
Description:	Based on observation the facility failed to ensure that the fire and emergency evacuation drawing contained all required items. Evidence: The facility?s fire and emergency evacuation drawing did not include secondary escape routes and telephones. Photographic evidence was taken.
Plan of Correction:	Administrator created and posted new drawings.
Standard #:	22VAC40-73-980-C
Description:	Based on an interview with staff, the facility failed to check the first aid kit at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence: Staff # 3 stated that the first aid kit was last checked in March 2021. No documentation was provided.
Plan of Correction:	Administrator made a check list and placed on the first aid kit to be checked monthly.
Standard #:	22VAC40-73-980-H
Description:	Based on observation and an interview with staff the facility failed to ensure the availability of a 96-hour supply of emergency food and drinking water. At least 48 hours of the supply must be on site at any given time, of which the facility?s rotating stock may be used. Evidence: Staff # 3 stated the facility?s emergency food supply had expired so they did not currently have an emergency food supply. The facility only had its regular daily food supply available.
Plan of Correction:	Administrator has created a list of emergency food and it is to be kept in a separate labeled area only to be used in an emergency.
Standard #:	22VAC40-73-990-C
Description:	Based on an interview with staff 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 did not have documentation of a practice exercise for a resident emergency. -Staff # 3 stated, ?It?s been done but we can?t find it.? No documentation was provided.
Plan of Correction:	Administrator created a new form to keep track of resident emergency procedures.
Standard #:	22VAC40-90-30-B
Description:	Based on observation and interview with staff the facility failed to ensure that the sworn statement or affirmation shall be completed for all applicants for employment. Evidence: -The facility did not have a sworn statement or affirmation for Staff # 4 (date of hire: 8-8-22).
Plan of Correction:	Administrator will ensure that the sworn statement or affirmation will be completed for all applicants on the first day of employment.
Standard #:	22VAC40-90-30-B
Description:	Based on observation and interview with staff the facility failed to ensure that the sworn statement or affirmation shall be completed for all applicants for employment. Evidence: -The facility did not have a sworn statement or affirmation for Staff # 4 (date of hire: 8-8-22).
Plan of Correction:	Administrator will ensure that