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: May 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

Comments:

Type of inspection: Monitoring Date(s) of inspection: 05-13-2022 Time the licensing inspector was on-site at the facility for each day of the inspection: 4:30 p.m. ? 6:54 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on regarding allegations in the area(s) of: Staffing and Supervision Resident Care and Related Services Buildings/Grounds Number of residents present at the facility at the beginning of the inspection: 28 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 05 Number of staff records reviewed: 04 Number of interviews conducted with residents: 02 Number of interviews conducted with staff: 02 Observations by licensing inspector: buildings/grounds Additional Comments/Discussion: Focused inspection on self-reported incidents. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: 1) Personnel A violation notice was issued; any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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. 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 #:	22VAC40-73-250-B
Description:	VIOLATION: Based upon the staff record review, the facility failed to retain all staff records at the facility. EVIDENCE: The facility failed to have two out of four staff records available during the monitoring inspection. Staff record #3 and staff record #4 were not accessible during the monitoring inspection. Risk Rating: B-1
Plan of Correction:	Staff record #3 and Staff record #4 , no longer employed
Standard #:	22VAC40-73-250-C
Description:	VIOLATION: Based upon the staff record review, the facility failed to maintain all required documentation in each staff record. EVIDENCE: Staff record #1 and staff record #2 failed to have each of the following items: a date of hire, a criminal record report, a sworn disclosure statement, and an orientation training document. Risk Rating: B-1
Plan of Correction:	Staff record #3 no longer employed. Staff record #2 Date of Hire : 04/26/2022, Criminal Record report -4-26-2022. Sworn Disclosure statement -04-19-22. Orientation training document - 04-26-2022.