VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Atkinson's Retirement Home
4001 Elmswell Drive
Richmond, VA 23223
(804) 236-0175

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: Aug. 21, 2023 and Aug. 25, 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 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

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: 8-21-23 from 11:00 a.m.- 1:35 p.m. and 8-25-23 from 7:50 a.m.- 8:30 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: 8 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection: facility documentation, facility postings, first aid kit, emergency food and water. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records the facility failed to ensure that each staff person shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: The record for Staff #1 (date of hire: 3-20-18) contained a TB screening last dated 7-24-22.
Plan of Correction:	Administrator got the TB test done and put the next due date on the calendar.
Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records the facility failed to ensure that each direct care staff member shall maintain current certification in first aid. Evidence: The record for Staff # 2 (date of hire: 10-1-2-2020) contained first aid certification that expired 7-1-23.
Plan of Correction:	Administrator added CPR and First Aid due dates for all employees to the calendar.
Standard #:	22VAC40-73-260-B
Description:	Based on a review of staff records the facility failed to ensure that there shall be at least one staff person in each building at all times who has current certification in CPR. Evidence: The record for Staff # 2 (date of hire: 10-1-2-2020) contained CPR certification that expired 7-1-23.
Plan of Correction:	Staff # 2 completed CPR and First Aid class and due date was added to the calendar.
Standard #:	22VAC40-73-310-D
Description:	Based on a review of resident records the facility failed to ensure that based upon review of the UAI prior to admission of a resident, the assisted living facility administrator shall provide written assurance to the resident that the facility has the appropriate license to meet his care needs at the time of admission. Copies of the written assurance shall be given to the legal representative and case manager, if any, and a copy signed by the resident or his legal representative shall be kept in the resident's record. Evidence: The record for Resident # 3 (admit date: 3-1-23) did not contain written assurance.
Plan of Correction:	Administrator put written assurance document in all resident records.
Standard #:	22VAC40-73-410-A
Description:	Upon admission, the assisted living facility shall provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record. Evidence: The record for Resident # 3 (admit date: 3-1-23) did not contain acknowledgment of having received the orientation.
Plan of Correction:	Administrator put an orientation document in all resident records and had residents to sign it.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of resident and staff records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual and each staff person. Evidence of this review shall be the resident's, his legal representative's or responsible individual's, or staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record. Evidence: -The record for Resident # 2 (admit date: 7-20-2020) contained written acknowledgment of an annual review of resident rights last dated 1-1-22. -The record for Resident # 4 (admit date: 9-1-21) contained written acknowledgment of an annual review of resident rights last dated 1-1-22. -The record for Staff # 1 (date of hire: 3-20-18) contained written acknowledgment of an annual review of resident rights last dated 1-1-21.
Plan of Correction:	Administrator had all residents to sign Resident Rights review and will ensure this is completed the first month of each year.
Standard #:	22VAC40-73-650-E
Description:	Based on a review of resident records the facility failed to ensure the resident's record shall contain the physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's oral order. Orders shall be organized chronologically in the resident's record. Evidence: The record for Resident # 2 (med pass) did not contain signed physician?s orders.
Plan of Correction:	Administrator contacted the pharmacies to obtain all signed physician orders and placed signed orders in resident records.