VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Highland House
3501 Longdale Furnace Road
Clifton forge, VA 24422
(540) 862-4271

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Sept. 27, 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 inspectors were on-site at the facility for each day of the inspection: 09/27/2022 9:00AM until 1:20PM. 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: 11 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: tour of the facility?s physical plant, medication cart audit and medication pass 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-120-A
Description:	Based on staff record review and staff interview, the facility failed to ensure within the first seven working days of employment a staff person had the required orientation and training. EVIDENCE: The record for staff 1, date of hire 03/30/2022, did not contain documentation of new staff orientation. Interview with staff 4 confirmed this was accurate.
Plan of Correction:	By 10/9/2022, Staff 1 will have new hire orientation paperwork completed. Upon hire, Administrator or Designated employee in charge will ensure new hire has completed all required new hire paperwork.
Standard #:	22VAC40-73-250-D
Description:	Based on staff record review and staff interview, the facility failed to ensure a staff person had an annual tuberculosis (TB) evaluation. EVIDENCE: The most recent TB evaluation in the record for staff 2, date of hire 07/10/2019, was dated 01/07/2021. Interview with staff 4 revealed that staff 2 has not had a TB evaluation since 01/07/2021.
Plan of Correction:	TB Screening completed and sent to Medical Director on 9/30/2022 to sign off on.
Standard #:	22VAC40-73-290-B
Description:	Based on observation, the facility failed to implement their procedure for posting the name of the current on-site person in charge. EVIDENCE: When two licensing inspectors arrived for the facility's on-site inspection on 09/27/2022, staff 4 was posted as being the current on-site person in charge; however, staff revealed that staff 4 had not been to the facility and was on her way in.
Plan of Correction:	Provided in-service on posting person in charge properly each shift.
Standard #:	22VAC40-73-320-B
Description:	Based on resident record review and staff interview, the facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually on a resident. EVIDENCE: The record for resident 4 contained documentation that the most recent TB screening for the resident was completed on 08/25/2021. Interview with staff 4 revealed this was accurate.
Plan of Correction:	TB Screening completed & sent to Medical Director to sign off on. Administrator will review TB Screenings annually.
Standard #:	22VAC40-73-325-B
Description:	Based on resident record review and staff interview, the facility failed to ensure fall risks ratings were reviewed and updated annually. EVIDENCE: The uniform assessment instrument (UAI) for resident 4, dated 08/27/2021, assessed the resident as being assisted living level of care. The last fall risk rating for resident 4 was completed on 08/27/2021. Interview with staff 4 confirmed this was accurate.
Plan of Correction:	Fall risk on Resident 4 completed. Administrator will use tickler files to ensure Resident information Is kept up to date.
Standard #:	22VAC40-73-440-H
Description:	Based on resident record review and staff interview, the facility failed to ensure there was an annual reassessment using the uniform assessment instrument (UAI) for a resident. EVIDENCE: The most recent UAI in the record for resident 4 was dated 08/27/2021. Interview with staff 4 revealed that the resident's UAI has not been updated as required.
Plan of Correction:	UAI on Resident 4 completed. Administrator will use tickler files to ensure Resident information is kept up to date.
Standard #:	22VAC40-73-480-E
Description:	Based on resident record review and staff interview, the facility failed to ensure the physician's or other prescriber's orders, services provided, evaluations of progress, and other pertinent information regarding the rehabilitative services were recorded in the resident's record. EVIDENCE: During on-site inspection on 09/28/2022, staff 4 informed one licensing inspector that resident 4 has been receiving physical therapy services from a home health agency for one month. Staff 4 revealed; however, that there was no documentation at the facility from the home health agency regarding evaluations of progress and other pertinent information regarding resident 4.
Plan of Correction:	Administrator obtained documents from home health agency. Will in-service staff to ask for notes after each visit.
Standard #:	22VAC40-73-520-A
Description:	Based on observation during a tour of the facility's physical plant, the facility failed to ensure the current month's activities schedule was posted. EVIDENCE: During on-site inspection on 09/28/2022, one licensing inspector observed at approximately 9:46AM the activities calendar posted in the facility was from August 2022.
Plan of Correction:	Corrected up-to-date schedule and posted. Administrator will ensure timely posting.
Standard #:	22VAC40-73-550-G
Description:	Based on staff record review, resident record review and staff interview, the facility failed to ensure an annual review of resident rights was completed. EVIDENCE: 1. The record for staff 2, date of hire 07/10/2019, and staff 3, date of hire 07/25/2017, did not contain documentation that either staff have had an annual review of resident rights; the record for staff 3 contained documentation that the last review of resident rights for staff 3 was completed on 08/21/2019. Interview with staff4 confirmed this was accurate. 2. The record for resident 4 contained documentation that the resident has not had an annual review of resident rights since 08/27/2021. Interview with staff 4 confirmed this was accurate.
Plan of Correction:	Resident & Tickler will be utilized to ensure all Resident rights are done yearly.
Standard #:	22VAC40-73-610-B
Description:	Based on observation during a tour of the facility's physical plant, the facility failed to ensure the current week's menu for meals and snacks was posted. EVIDENCE: During on-site inspection on 09/28/2022, one licensing inspector observed at approximately 9:46AM the most recent date on the menu posted in the facility for breakfast, lunch, dinner, and snacks was 09/24/2022.
Plan of Correction:	Correct up-to-date menu posted. Administrator will ensure timely posting.
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the facility's physical plant, the facility failed to ensure cleaning products and other hazardous materials were stored in a locked place. EVIDENCE: During on-site inspection on 09/27/2022, one licensing inspector observed the door to room 23 to be unlocked. Room 23 contained bug killer, disinfectant spray and other multiple cleaning and floor maintenance products. Staff 5 informed the licensing inspector that the door to room 23 is supposed to be locked at all times.
Plan of Correction:	The door was shut immediately. Staff were in- serviced on the importance of ensuring these doors are shut.
Standard #:	22VAC40-73-870-A
Description:	Based on observation during a tour of the facility's physical plant, the facility failed to ensure the building was maintained in good repair and kept clean. EVIDENCE: 1. The front door frame has paint worn off in places. 2. There are soiled areas on the front door near the handle. 3. The outside of the building to the left of the front door has green streaks on the siding under a window air conditioner (AC}, and the top of the AC also has a green substance on it. Inside the building, the same window AC has a black substance in the right corners of the section that hold the unit in the window. 4. Near the back door, the floor planks are coming up at the ends; they appear to be warped, with the centers lower than the ends. 5. In the hall opposite room 10, there is a dent, or hole in the floor. It is approximately ? inch lower than the floor and approximately 2 inches by 2 inches in size. 6. There is an inoperable light in the hall outside room 10. 7. Room 16 has cracks in the tiles in the shower stall, no escutcheons around the water taps in the stall, and water damage to the inside of the closet located behind the shower stall. 8. The heating unit attached to the lower wall next to the toilet in room 14 is rusty, and bubbling through the paint. 9. The hall windows near room 1 have large cobwebs and numerous dead bugs caught in them.
Plan of Correction:	#1 & #2: The front door will be painted and repaired. #3: Outside of building will be pressure washed & will be visually observed for future cleaning needs & will be completed as needed. #4: Floor planks have been replaced. #5: Flooring will be replaced. #6: Light replaced. #7: The shower and wall will be repaired. #8: The wall with the heating unit will be repaired #9: Windows have been cleaned. Staff will follow cleaning checklist.
Standard #:	22VAC40-73-950-C
Description:	Based on observation and staff interview, the facility failed to ensure to enter into at least one agreement with a separate vendor capable of providing an emergency generator in the event that the primary vendor is unable to comply with its agreement with the facility during an emergency when a facility is no equipped with an onsite emergency generator. EVIDENCE: During on-site inspection, one licensing inspector observed that the facility does not have an on-site emergency generator and this was also confirmed by staff 4. Also, staff 4 revealed that the facility does not have a separate agreement with another vendor in the event that the primary vendor is unable to comply with its agreement with the facility during an emergency.
Plan of Correction:	Highland House had/has agreement in place with United Rentals to provide generator upon request.
Standard #:	22VAC40-73-950-E
Description:	Based on document review and staff interview, the facility failed to ensure a semi-annual review on its emergency preparedness and response plan for all staff, residents, and volunteers. EVIDENCE: Interview with staff 4 revealed that staff and residents have not participated in a semi-annual review of the facility's emergency preparedness and response plan during the year 2022.
Plan of Correction:	Emergency Preparedness & Response Plan In-service completed for Residents and the Staff. Administrator will ensure training calendar is completed and documented.
Standard #:	22VAC40-73-970-A
Description:	Based on documentation review and staff interview, the facility failed to ensure fire and emergency drills were completed as required. EVIDENCE: The document, record of required fire and emergency evacuation drills, provided by staff 4 during on-site inspection on 09/28/2022 contained documentation that a fire and emergency evacuation drill has not been completed since 07/18/2022 by staff 5. Interview with staff 4 confirmed this was accurate.
Plan of Correction:	All fire drills will be completed and up to date. Monthly fire drills will be performed & documented and will be added to the Tickler. A fire drill occurred on 9/27/2022 and has since been documented.
Standard #:	22VAC40-73-990-C
Description:	Based on document review and staff interview, the facility failed to ensure at least once every six months all staff currently on duty on each shift participated in an exercise in which the procedures for resident emergencies are practiced. EVIDENCE: Interview with staff 4 revealed that staff have not participated in an exercise in which procedures for resident emergencies are practiced during the year 2022 and that the last practice exercise was led by staff 5 in 2021.
Plan of Correction:	In-service completed. Administrator will ensure the training calendar and all mandatory trainings are completed and documented.