VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Elizabeth House Assisted Living
3590 Mountain Road
Glen allen, VA 23060
(804) 672-7580

Current Inspector: Belinda Dyson (804) 662-9780

Inspection Date: Jan. 14, 2022

Complaint Related: Yes

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: Complaint Date(s): January 14, 2023 Time the licensing inspector was on-site at the facility for each day of the inspection: 1:53 p.m. to 5:08 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/04/2022 regarding allegations in the area(s) of: Resident Care and Related Services Staffing and Supervision Administration and Administrative Services Number of residents present at the facility at the beginning of the inspection: 20. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 08 Number of staff records reviewed:0. Number of interviews conducted with residents:0. Number of interviews conducted with staff: 01. Observations by licensing inspector: Resident Records, buildings/grounds, Infection Control Policies and MARS/Physician Orders. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all the allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services Staffing and Supervision Administration and Administrative Services A violation notice was issued; any violation(s) not related to the complaints but identified during the investigation can also be found on the violation notice. The licensee can submit a plan of correction to indicate how the cited violation(s) will be addressed 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 #:	22VAC40-73-40-A
Complaint related:	No
Description:	VIOLATION: Based upon observation and policy review, the facility failed to adhere to their policies and procedures concerning visitation during the COVID-19 Pandemic. EVIDENCE: Upon entering the facility on January 14, 2022, the facility failed to have staff accessible to provide entrance screenings for each visitor that entered the facility by conducting temperature checks, questions about possible symptoms, visitor attestation forms/educational packets, and accessible face mask covering. Per the facility?s Visitation During the COVID-19 Pandemic policy states the following: The Visit: 1) The staff member supervising the visitation will greet visitor(s) and supply them with an appropriate face mask (3ply or N95 is required) and have them perform hand hygiene with ABHR. 2) Visitor(s) will be screened using the visitor attestation form and will be provided with an educational packet. 3) Visitors will be asked to read and sigh the Visitation agreement. (attached) A) Agreement must be signed in order to move forward with the visit. B) Explain to the visitor(s) that any breach in agreement will result in the visit being terminated.
Plan of Correction:	Temperature stations, attestation forms, hand sanitizer, 3 ply face masks, are readily available to all visitors of staff Visitation agreement no longer mandatory as COVID requirements have been lifted
Standard #:	22VAC40-73-280-A
Complaint related:	Yes
Description:	VIOLATION: Based upon observation and staff interviews, the facility failed to have sufficient staff in numbers. EVIDENCE: Upon entering the facility, the licensing representative was greeted by a family member that was searching for a direct care staff member to provide direct care assistance to a resident in room #201. The only staff member available at the time of the family?s request was a dietary staff member who attempted to locate a C.N.A., P.C.A. or Med Tech. Upon speaking with both dietary and direct care staff members, in each interview, staff members expressed concerns about staffing shortages. The administrator also confirmed, during the interview session, that the facility had staffing shortages and that she was in negotiations with a staffing agency to address the identified staffing issues. Risk Rating: B-1
Plan of Correction:	Staffing is stable through new staff and or agency usage.
Standard #:	22VAC40-73-290-A
Complaint related:	No
Description:	VIOLATION: Based upon the record review, the facility failed to maintain a written work schedule that identified the names and job classification of all staff working each shift, with an indication of the in-charge person at any given time. EVIDENCE: The master schedule submitted to the licensing inspector on January 14, 2022, failed to have the following item: 1) Indication of the in -charge staff member at any given time. Risk rating: A-1
Plan of Correction:	Master schedule revised to indicate in -charge staff member. ED, RCC, and Med Tech on duty in lobby daily.