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: Feb. 10, 2023

Complaint Related: Yes

Areas Reviewed:

AREAS OF STANDARDS ? 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:

The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the investigation can 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 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 #:	22VAC40-73-560-F
Complaint related:	No
Description:	: Based upon the complaint inspection, the facility failed to ensure that all records shall be made available for inspection by the department's representative. EVIDENCE: During the February 10, 2023, complaint inspection, the department?s representative met with the designated staff member to initiate the complaint inspection. Upon notice, the designated staff member informed the department?s representative that she did not have access to the resident records. During the exit conference with the designed staff member, the administrator arrived and informed the department?s representative that she did not have access to the records and that she could email the requested documents.
Plan of Correction:	All discharged resident files are kept locked in the administrator?s office. Files have been reorganized and Staff educated on the location of discharged files.