VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Holly Manor AL IL Operations LLC
2005 Cobb Street
Farmville, VA 23901
(434) 392-6106

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: Oct. 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 22VAC40-73 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

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: 10-5-23 from 10:15 a.m.-3:15 p.m. and 10-11-23 from 10:25 a.m.- 1:25 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: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection-facility documentation, facility postings, first aid kit, lunch meal/menu, medication pass, physician?s orders, medication administration records (MARs), and emergency food and water supply. 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 #:	22VAC40-73-50-B
Description:	Based on a review of resident records the facility failed to ensure that written acknowledgment of the receipt of the disclosure by the resident or his legal representative shall be retained in the resident's record. Evidence: The record for Resident # 4 (admit date: 1-10-23) did not contain written acknowledgment of the receipt of the disclosure.
Plan of Correction:	Signed written acknowledgement of the receipt of the disclosure for Resident #4 was obtained and placed in the resident chart. All resident charts have been audited to ensure that disclosure documentation has been obtained as required. Chart audit processes have been reviewed to ensure oversight and education was provided to staff on required admission paperwork.
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:12-14-22) did not contain documentation of first aid certification and only contained CPR certification.
Plan of Correction:	Staff #2 has been removed from the schedule until completion of first aid certification. All staff records have been audited to ensure that all required certifications are up to date. HR Director educated by administrator to ensure compliance with the first aid certification requirement for all direct care staff.
Standard #:	22VAC40-73-320-A
Description:	Based on a review of resident records the facility failed to ensure that the resident?s physical examination report shall be on file at the assisted living facility. Evidence: The record for Resident # 5 (admit date: 11-17-22) did not contain a physical examination report.
Plan of Correction:	Physical examination report added to the Resident #5?s chart. Chart audit of all residents was completed to ensure documentation is in place. Rehabilitation department and social worker from SNF notified of proper documentation requirements as part of admission process to ALF. ALF staff educated on review of all charts to ensure that physical examination reports documentation is in place.
Standard #:	22VAC40-73-380-B
Description:	Based on a review of resident records the facility failed to ensure that the required personal and social information required shall be placed in the person's record and kept current. Evidence: The record for Resident # 2 (admit date: 1-27-23) did not contain the resident?s personal and social information.
Plan of Correction:	Document completed by family and placed in Resident #2?s record. All resident charts audited to ensure that personal and social information documentation has been included. Staff education provided on required documentation to be completed upon admission to assisted living facility with auditing of all new admission paperwork.
Standard #:	22VAC40-73-410-A
Description:	Based on a review of resident records the facility failed to ensure that 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 # 2 (admit date: 1-27-23) did not contain documentation of acknowledgment of having received the orientation.
Plan of Correction:	Resident #2 was provided with orientation to the facility including mealtimes, use of call system, and emergency response procedures. All resident charts audited to ensure acknowledgement of orientation. Education was provided to staff on required orientation documentation for residents and auditing of all new admission paperwork.
Standard #:	22VAC40-73-430-H-2
Description:	Based on a review of resident records the facility failed to ensure that a copy of the written discharge statement shall be retained in the resident's record. Evidence: The record for Resident # 3 (discharge date: 3-30-23) did not contain a discharge statement.
Plan of Correction:	A copy of the written discharge statement was added to Resident #3?s record. Education was provided to staff on the required discharge statements which require signature upon discharge. Discharged resident charts audited to ensure that the required discharge statement is present. Education provided to staff on ensuring discharge paperwork is in place and timely auditing of recently discharged resident charts.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of resident 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 as stipulated in subsection H of this section. Evidence of this review shall be the resident's, his legal representative's or responsible individual'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 # 9 (admit date: 3-21-18) contained a written acknowledgment of a review of resident rights and responsibilities last dated 3-18-22.
Plan of Correction:	Signed written acknowledgement of the review of Resident #9?s rights and responsibilities has been obtained and placed in Resident #9?s chart. All resident charts have been audited to ensure that resident?s rights documentation has been updated as required. Chart audit processes have been reviewed to ensure oversight and education was provided to staff on regulation regarding when resident rights are to be reviewed and signed.
Standard #:	22VAC40-73-950-E
Description:	Based on a review of facility documentation the facility failed to ensure that the facility shall develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating. The orientation and review shall cover responsibilities for: 1. Alerting emergency personnel and sounding alarms; 2. Implementing evacuation, shelter in place, and relocation procedures; 3. Using, maintaining, and operating emergency equipment; 4. Accessing emergency medical information, equipment, and medications for residents; 5. Locating and shutting off utilities; and 6. Utilizing community support services. Evidence: The facility did not provide documentation of a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities.
Plan of Correction:	Emergency preparedness and response exercise was conducted with staff and residents on 10/19/23 addressing all responsibilities (alerting emergency personal, sounding alarms, implementing evaluation, shelter in place, relocation procedures, using/maintaining/operating emergency equipment, accessing emergency medical information, equipment and medications for residents, locating and shutting off utilities and utilizing community support for services). Facility Director of Safety educated by Administrator to ensure all semi-annual reviews on the emergency preparedness and response plan for all staff, residents, and volunteers with emphasis placed on an individual?s respective responsibilities will be conducted as required.
Standard #:	22VAC40-73-990-C
Description:	Based on an interview with the administrator, the facility failed to ensure that at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Evidence: The administrator stated that the facility had not conducted a practice exercise for a resident emergency since July 2022.
Plan of Correction:	The Director of Safety was educated by the Administrator to ensure resident emergency practice exercises are completed as required.