VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Atkinson's Retirement Home
4001 Elmswell Drive
Richmond, VA 23223
(804) 236-0175

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: Oct. 25, 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

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: 10-25-22 from 10:05 a.m.- 12:55 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: 8 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: 3 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection: facility documentation, facility postings, first aid kit, emergency food and water supply, physician?s orders/Medication Administration Records (MARs), 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 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 #:	22VAC40-73-410-A
Description:	Based on a review of resident records the facility failed to ensure that upon admission, the assisted living facility shall provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident?s record. Evidence: The record for Resident # 2 (admit date: 2-1-22) did not contain an acknowledgment of orientation. The administrator stated that the resident was oriented at admission but it was not documented.
Plan of Correction:	Administrator created an orientation checklist for the POA and resident to sign.
Standard #:	22VAC40-73-430-H-2
Description:	Based on a review of resident records the facility failed to ensure that at the time of discharge a copy of the discharge statement shall be retained in the resident?s record. Evidence: The record for Resident # 1 (discharge date: 2-12-22) did not contain a discharge statement. The administrator stated that she forgot to complete the discharge statement.
Plan of Correction:	Administrator completed a discharge statement on all discharged residents and put a blank form in all resident records to prevent failure of completing a form in the future.
Standard #:	22VAC40-73-490-A-2
Description:	Based on a review of facility documentation the facility failed to ensure that a licensed health care professional, practicing within the scope of his profession, shall provide health care oversight at least every six months, or more often if indicated, based on his professional judgment of the seriousness of a resident?s needs or stability of a resident?s condition. Evidence: The facility?s healthcare oversight was last dated 3-1-22. The administrator stated that she would ensure that the healthcare professional was contacted to complete another healthcare oversight.
Plan of Correction:	Administrator notified the facility's RN to complete the oversight. The RN has completed an oversight and will return in 3 months.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of staff records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities were reviewed annually with each staff person and that evidence of this review shall be the staff person's written acknowledgement of having been so informed, which shall include the date of review and shall be filed in the staff person?s record. Evidence: The record for Staff # 1 (date of hire: 4-7-18), Staff # 2 (date of hire: 10-1-2020), and Staff # 3 (date of hire: 3-20-18) contained an annual review of resident rights last dated 1-1-21. The administrator stated that she will ensure all that the review of resident rights will be updated for all staff.
Plan of Correction:	A resident rights and responsibilities form/policy was reviewed and signed by employees. A copy has been placed in their files after they signed and read the policy.
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. Evidence: The record for Resident # 1 (med pass) contained a physician?s order sheet that was not signed by the physician. The administrator stated she thought the order was electronically signed.
Plan of Correction:	Administrator contacted Cedarfield Pharmacy regarding all signed orders and was given another copy of the actual prescription (signed by the prescribing doctor) to show the licensing inspector.
Standard #:	22VAC40-73-925-B
Description:	Based on a tour of the facility the facility failed to ensure that common face/hand washing sinks shall have liquid soap for hand washing. Evidence: During a tour of the facility with the administrator the licensing inspector observed that the liquid soap dispenser in the downstairs common bathroom did not contain soap. The administrator stated that she would have the liquid soap dispenser refilled.
Plan of Correction:	The liquid hand soap was refilled.
Standard #:	22VAC40-73-925-C
Description:	Based on a tour of the facility the facility failed to ensure that residents may not share bar soap. Evidence: During a tour of the facility with the administrator the licensing inspector observed bar soap on the sink in the downstairs common bathroom. (Photographic evidence was taken). The administrator stated that the bathroom is shared by four residents and she would ensure that the residents use only the liquid hand soap.
Plan of Correction:	The residents and staff were told not to use bar soap. The bar soap was discarded and replaced with liquid soap.
Standard #:	22VAC40-73-950-E
Description:	Based on a review of facility documentation the facility failed to ensure the semi-annual review of its emergency preparedness and response plan. Evidence: The facility?s review of the emergency preparedness and response plan was dated 1-8-22. The administrator stated that she thought it was an annual review.
Plan of Correction:	The administrator has reviewed the semi-annual emergency preparedness and response plan with staff and residents. Everyone present has signed the policy. The administrator has posted on the calendar when the review is due again.
Standard #:	22VAC40-73-980-A
Description:	Based on a review of the facility?s first aid kit the facility failed to ensure that the first aid kit included all required items. Evidence: The first aid kit did not contain a thermometer. The administrator stated that she would replace the kit?s thermometer.
Plan of Correction:	Administrator reviewed VDSS first aid checklist and put all listed items in first aid kit.