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: June 14, 2023

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 GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/14/2023 9:30 a.m.-1:00 p.m. 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: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Lunch meal, activities, medication administration, physician?s orders, first aid kit supplies Additional Comments/Discussion: Administrator and staff members were given the opportunity to ask questions. Inspector was accompanied by Licensing Administrator. 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 Belinda Dyson, Licensing Inspector at (804) 662-9780 or by email at belinda.dyson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-B
Description:	During a review of staff records, one out of eight records reviewed did not have documentation of required annual training hours. Evidence: Staff record #1 did not have documentation of 18 hours of required training. None were noted in the record.
Plan of Correction:	Will ensure that employee?s 18 hours of required annual training is in employee records.
Standard #:	22VAC40-73-250-D
Description:	During a review of staff records three of four records reviewed did not have current or initial tuberculosis test or screening results documented. Evidence: Staff #1 last TB results is dated 3/8/2022. Staff #2 and #3 did not have an initial TB results or screening to review upon hire. They were hired on 7/3/2022 and 5/17/2022 respectively.
Plan of Correction:	Audit of all employee files reviewed for current tuberculosis test or screening. Any findings out of compliance were addressed. Tests will be kept in separate notebook divided by months to ensure that we remain in compliance with the annual screening. Tuberculosis is part of the orientation packet and completed during orientation.
Standard #:	22VAC40-73-550-G
Description:	During a review of resident's records, four our of eight records reviewed did not have documentation of annual review of residents rights and responsibilities. Evidence: Resident's records #1, #5, #6 and #8 rights were dated 1/19/2022.
Plan of Correction:	Audit of all current resident files reviewed for their annual review of resident rights. Any resident missing the annual review will be completed and placed in resident?s file. Annual review of resident rights will be offered several times to accommodate the schedules of our residents.
Standard #:	22VAC40-73-870-A
Description:	During a tour of the physical plant, all areas were not clean. Evidence: Observations in hallways throughout were areas of soiled or dark stained carpet.
Plan of Correction:	Hallways have been deep cleaned to remove areas of soiled/dark stained carpet. Housekeeping notified to keep carpet cleaning in common areas on a monthly schedule.