VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bridgeforth Manor
2683 Washington Avenue Ext.
Victoria, VA 23974
(434) 696-3461

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Dec. 13, 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

Technical Assistance:

Technical assistance provided regarding the renewal application and the VDSS website for resource, Division memos, forms and other resources.

Comments:

Type of inspection: Renewal Date(s) of inspection: 12/13/202 and Time:- 3:00 pm to 5:02 p.m. the licensing inspector was on-site at the facility for each day of the inspection: 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: 4 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 03 Number of staff records reviewed:02 Number of interviews conducted with residents:01 Number of interviews conducted with staff: 02 Observations by licensing inspector: meal observation and medication administration pass Additional Comments/Discussion: 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, Vashti Colson, Licensing Inspector at (804) 662-9432 or by email at Vashti.Colson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-A
Description:	VIOLATION: Based upon the record review, the facility failed to have the physical examination of each resident on file. EVIDENCE: Record #1 failed to have a physical examination accessible during the renewal record review.
Plan of Correction:	Record #1 failed to have a physical examination accessible, Administration scheduled a physical for the resident . The physical will be placed in the chart.
Standard #:	22VAC40-73-870-A
Description:	VIOLATION: Based upon the building tour, the facility failed to maintain some portions of the interior or exterior of the building. EVIDENCE: The following items require repair: 1) The sunroof window in room #4 has a wood covering that displayed water stains and buckling wood. 2) A portion of the wall in room # 4 has a large crack in the plaster that requires repair.
Plan of Correction:	The sunroof window in room #4 will be repaired so that there I no buckling wood. The wall in room #4 that requires plaster will be repaired.
Standard #:	22VAC40-73-925-B
Description:	VIOLATION: Based upon the building tour, the facility failed to have paper towels or an air dryer in each bathroom. EVIDENCE: Bathroom #2 failed to have paper towels accessible or available during the renewal study building tour.
Plan of Correction:	Bathroom #2 failed to have paper towel. Staff placed paper towel in the bathroom during the renewal inspection.