VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Fort Shelby Manor
200 Solar Street
Bristol, VA 24201
(276) 669-3562

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: March 9, 2023 , March 23, 2023 and March 29, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/09/2023 2:25pm to 3:48pm, 03/23/2023 12:40pm to 1:00pm, 03/29/2023 3:07pm to 3:12pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 03/08/2023 regarding allegations in the area(s) of: Personnel and resident care and related services. Number of residents present at the facility at the beginning of the inspection: 39 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were 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. 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-460-A
Description:	Based on facility self-report and interviews with staff and one resident, the facility failed to assume general responsibility for the health, safety and wellbeing of one resident. EVIDENCE: 1. Staff #1 notified LI on 03/08/2023 via phone and on 03/09/2023 via written report an incident had occurred at the facility on 03/04/2023 at approximately 7:00am, in which staff #4 ?ran down the steps and put his hands around his neck (resident #1) to choke him, cursing him.? 2. Resident #1 reported in an interview with LI on 03/09/2023 ?I woke up in the morning,? had ?mental pain, weird feelings in my head? and ?I screamed two or three times.? Reported staff #4 ?came down the stairs? and ?put me in a choke hold and pushed me down in a chair.? 3. Staff #2 reported in an interview with LI on 03/23/2023 ?It was a little before 7:00am. I was in the kitchen and heard resident 1 yelling.? Staff #2 reported she checked on the resident and returned to the kitchen. Staff #2 noted a short time later she was called by staff #3 to the living room and observed staff #4 ?had one hand on resident #1?s neck.? Staff #2 stated ?I thought he (staff #4) may have been asleep and it startled him.? 4. Staff #3 reported in an interview with LI on 03/27/2023 ?It was at the beginning of med pass. Resident #1 was waking up. I believe he was hallucinating; he mentioned another resident putting thoughts in his head.? Staff #3 reported resident #1 was ?pretty loud.? Staff #3 stated staff #4 ?came downstairs cursing and placed his hands on his (resident #1) throat and started choking him.?
Plan of Correction:	Administrator will remind all staff of the Residents Rights and Responsibilities with an individual copy to each staff. Also, Administrator will advise each staff person that they are expected to treat each Resident with respect, courtesy, and consideration at all times. Any new Resident will be assured that their Resident Rights will be observed. [SIC]
Standard #:	22VAC40-73-550-C
Description:	Based on facility self-report and interviews with staff and one resident, the facility failed to ensure a resident has the rights and responsibilities as provided in ? 63.2-1808 of the Code of Virginia. EVIDENCE: 1. Section 63.2-1808 of the Code of Virginia includes the following: a. Any resident of an assisted living facility has the rights and responsibilities enumerated in this section. The operator or administrator of an assisted living facility shall establish written policies and procedures to ensure that, at the minimum, each person who becomes a resident of the assisted living facility: i. Is free from mental, emotional, physical, sexual, and economic abuse or exploitation; is free from forced isolation, threats or other degrading or demeaning acts against him; and his known needs are not neglected or ignored by personnel of the facility; ii. Is treated with courtesy, respect, and consideration as a person of worth, sensitivity, and dignity; 2. Staff #1 notified LI on 03/08/2023 via phone and on 03/09/2023 via written report an incident had occurred at the facility on 03/04/2023 at approximately 7:00am, in which resident #1 ?was in his room having a mental breakdown, as described by him (resident #1) when?a staff member (staff #4) ran down the steps and put his hands around his neck to choke him, cursing him.? 3. Resident #1 reported in an interview with LI on 03/09/2023 ?I woke up in the morning,? had ?mental pain, weird feelings in my head. I screamed two or three times.? Resident #1 reported staff #2 and staff #3 ?came into the room.? Resident #1 stated staff #4 ?came down the stairs cussing me left and right? and said ?You want me to beat the heck out of you?? Resident #1 reported staff #4 ?put me in a choke hold and pushed me down in a chair.? 4. Staff #2 reported in an interview with LI on 03/23/2023 ?It was a little before 7:00am. I was in the kitchen and heard resident 1 yelling.? Staff #2 reported she checked on the resident and returned to the kitchen. Staff #2 noted a short time later she was called by staff #3 to the living room and observed staff 4 ?had one hand on resident #1?s neck.? Staff #2 stated ?I thought he (staff #4) may have been asleep and it startled him.? 5. Staff #3 reported ?It was at the beginning of med pass. Resident #1 was waking up. I believe he was hallucinating; he mentioned another resident putting thoughts in his head.? Reports resident #1 was ?pretty loud.? Stated ?Staff #4 came downstairs cursing and placed his hands on his (resident #1) throat and started choking him.? Staff #3 reported staff #4 said to resident #1, ?I?m tired of you making so much f?ing noise.?
Plan of Correction:	Staff #4 has been fired. Administrator will make sure that all staff, present or future, understand that no Resident is to be mistreated in any way and that their rights will be observed at all times. [SIC]