VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Covenant Columns
510 Park Avenue
Richmond, VA 23223
(804) 222-5133

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: May 18, 2023

Complaint Related: No

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: 5-18-2023, 10:01 -11 a.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: 9 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review and interview with staff, the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. Evidence: Resident #1 admitted 2-10-2023. Resident #1 did not have a physical examination in the record. Staff #1 confirmed during inspection that Resident #1 did not have a physical examination on file.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-A
Description:	Based on record review and interview with staff, the facility failed to ensure that on or within seven days prior to the day of admission, a preliminary plan of care shall be developed to addressed the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: Resident #1 admitted 2-10-2023. As of the date of inspection on 5-18-2023, the resident did not have an ISP on file. Staff #1 confirmed during inspection that Resident #1 did not have an ISP on file.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview with staff, the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs based upon the uniform assessment instrument (UAI). Evidence: Resident #2 admitted 5-09-2023. Resident #2?s UAI dated 5-05-2023 documented, ?mechanical and human help, physical assistance with bathing, toileting, and transferring?; however, Resident #2?s ISP dated 5-09-2023 did not identify mechanical assistance for bathing, toileting, or transferring. Additionally, Resident #2?s UAI documented ?bowel and bladder incontinence, weekly or more? but that was not identified on ISP; and ?yes? to the services ?meal preparation, money management, transportation, shopping, phone use and home maintenance?; however, none of the services were addressed on the resident?s ISP.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview with staff, the facility failed to ensure the interior of the building was maintained in good repair. Evidence: There was a large, leaking portion of the ceiling on the first floor in the hallway leading to resident restroom/common area/dining. Staff #1 confirmed ?the leak began 3-4 days back and is due to plumbing.? Photographic evidence of the large brown water spot and leaking obtained on 5-18-2023 (date of inspection).
Plan of Correction:	Not available online. Contact Inspector for more information.