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: June 5, 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 GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 06/05/2023, 9:45am to 3:50pm 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: 41 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: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-250-C
Description:	Based on a review of staff records, the facility failed to verify that each staff person has received a copy of his or her current job description. EVIDENCE: 1. The hire date for staff #4 was 12/04/2022; the record for staff #4 did not contain acknowledgement of receipt of a copy of her current job description.
Plan of Correction:	Staff #4 has received a copy of her duties. In the future, any new staff person will receive a copy of her or his duties by the Administrator when hired. [SIC]
Standard #:	22VAC40-73-280-A
Description:	Based on observations and conversations during the tour of the kitchen, the facility failed to have staff adequate in knowledge, skill, and abilities to maintain the well-being of each resident determined by individualized service plans. EVIDENCE: 1. Staff #7 stated she was waiting for staff #6 to purchase ?special foods? for her to serve the residents on special diets. 2. Staff #7 appeared to be having an extremely difficult time reading the list of residents on special diets which was posted in the kitchen; she states she does not require glasses for visual aid. She was not able to read the list which listed residents #9, #11, #12, #13, and #14 as all having special diets.
Plan of Correction:	The posted Special Diet list that is in the kitchen has been enlarged so that the cook can more easily see. Administrator will review special diet requirements with the cook. This will be done in the next 7 days. [SIC]
Standard #:	22VAC40-73-380-A
Description:	Based on a review of resident records, the facility failed to obtain all required personal and social information prior to or at the time of admission for two residents. EVIDENCE: 1. The Person/Social Data form for resident #8 did not contain information regarding resident strengths. 2. The Person/Social Data form for resident #5 did not contain information regarding resident strengths.
Plan of Correction:	The Residents who were missing strengths on their personal and social information forms have been documented by the Administrator. In the future strengths will be addressed on the personal and social data form upon admission. [SIC]
Standard #:	22VAC40-73-540-A
Description:	Based on observations made during the tour of the building, the facility failed to allow daily visits to residents in the facility. EVIDENCE: 1. On the glass entrance door to the women?s house there was a handwritten sign stating, ?No visitors allowed except for medical reasons.?
Plan of Correction:	The "No Visitors" signs have been taken down. All residents are allowed daily visits, unless we have an outbreak that requires having no visitors. [SIC]
Standard #:	22VAC40-73-610-E
Description:	Based on observations made during the tour of the kitchen, the facility failed to have a dietary manual available. EVIDNECE: 1. When the LI asked kitchen staff #7 where the dietary manual was located, she stated she did not have access to a dietary manual.
Plan of Correction:	We do have a Dietary Manual which was located in the cabinet near the Med Cart and not in the kitchen. It is now in the kitchen where the cook has access to it. [SIC]
Standard #:	22VAC40-73-650-A
Description:	Based on observations made during the noon medication pass, the facility failed to have a valid physician?s order to discontinue one medication for one resident. EVIDENCE: 1. Resident #9 is prescribed Fluticasone prop 50mcg nasal spray, use two sprays in each nostril daily. Documented on the MAR for 05/18/2023-06/16/2023, there is a handwritten note stating this medication was discontinued on 06/01/2023. 2. Staff #6 stated she recalled the doctor stating he wanted to discontinue this medication for this resident but she was not able to locate the order while the LI was present. Staff #6 had the pharmacy to fax the order to the facility while the LI was present.
Plan of Correction:	In the future, the Administrator will see that no medication orders will be implemented until we have the actual doctors order on the premises. [SIC]
Standard #:	22VAC40-73-680-I
Description:	Based on observations made during the audit of the noon medication pass, the facility failed to include the initials of staff when administering medications on individual MARs. EVIDENCE: 1. Resident #9 is prescribed Clonazepam 0.5mg, take one tablet by mouth two times daily. According to the MAR dated 05/18/2023-06/16/2023, the med tech did not initial when the medication was administered at the 8pm dose on 06/04/2023. 2. Resident #10 is prescribed Calcium 500-Vit D3 200 tablet, take two tablets by mouth twice daily and Melatonin 3mg tablet, take one tablet by mouth at bedtime. According to the MAR dated 05/18/2023-06/16/2023, the med tech did not initial when the Melatonin was administered at the 8pm dose on 06/03/2023 as well as Calcium administered at the 5pm dose on 06/04/2023.
Plan of Correction:	Med Techs will be reminded to document on the MAR when a medication is given. Also, Med Techs will be reminded of the procedures for documenting medications. Administrator will monitor the administration record weekly to see that all meds given are properly documented. [SIC]
Standard #:	22VAC40-73-750-B
Description:	Based on observations made during the tour of the building, the facility failed to provide a sturdy chair for each resident in the resident?s bedroom. EVIDENCE: 1. Resident room #7 had three beds and three residents in the room. There were only two chairs available in room #7. 2. Resident room #10 had four beds and four residents in the room. There were only three chairs available in room #10. 3. Resident room #2 had three beds and three residents in the room. There were only two chairs available in room #2.
Plan of Correction:	The Administrator will see that the required number of chairs are in each bedroom so that each resident has a chair. [SIC]
Standard #:	22VAC40-73-750-E
Description:	Based on observations made during the tour of the building, the facility failed to have clean bed linens for one resident. EVIDENCE: 1. The first bed on the right in the bedroom off the dining area in the men?s house was found to have several brown spots on the fitted sheet.
Plan of Correction:	Administrator will meet staff at Building #2 and go over the linen changing and laundry schedule to make sure that every resident has clean linens. [SIC]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the tour of the building, the facility failed to maintain the interior and exterior of all buildings in good repair. EVIDENCE: 1. The exterior of the men?s house and the women?s house was observed to have cracks and peeling white paint on the upper area trim of the front porches. 2. The common bathroom in the downstairs area of the men?s house located near the dining area was observed to have brown stains perhaps from water damage at the base of the toilet where it sits on the floor.
Plan of Correction:	Administrator is trying to find help at a price that we can afford to repair and paint the outside areas of the facility that need attention. Administrator will continue to try to meet this requirement. Administrator will see that the water damage at the base of the toilet is repaired by two weeks. [SIC]
Standard #:	22VAC40-73-870-B
Description:	Based on observations made during the tour of the building, the facility failed to keep areas free from foul odors. EVIDENCE: 1. The downstairs common bathroom, in the men?s house, near the dining area had a strong foul odor of urine.
Plan of Correction:	Administrator will meet with staff about proper cleaning and omitting bad odors near the dining area. Administrator will check daily to see that the house is free of foul and offensive odors, especially in the odor of urine. [SIC]
Standard #:	22VAC40-90-40-B
Description:	Based on a review of staff records, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The date of hire for staff #2 was 09/25/2022; the criminal history record was requested on 11/15/2022. 2. The date of hire for staff #4 was 12/04/2022; the criminal history record was requested on 01/09/2023.
Plan of Correction:	In the future, when hiring a new staff, the Administrator will see that the criminal history record is ordered within 30 days of hire. [SIC]