VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Candle Light Senior Manor
912 Maple Grove Drive
Richmond, VA 23223
(804) 716-3114

Current Inspector: Belinda Dyson (804) 662-9780

Inspection Date: Dec. 20, 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 22VAC40-80 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: 12/20/2023 from 10:15 a.m.-1:00 p.m. and on 1/4/2024 from 4:30 p.m.-5:30 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: 10 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: 5 Number of interviews conducted with staff: 3 Observations by licensing inspector: physical plant, physician?s orders, medications, medication administration records, first aid kit supplies Additional Comments/Discussion: Administrator and staff members were given the opportunity to ask questions 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 #:	22VAC40-73-250-C
Description:	Based on a review of staff records, 2 of the 3 records reviewed did not have current TB test results or screening available for review. Evidence Staff #2 and #3 did not have current TB screenings for review. Last date 3/2022.
Plan of Correction:	Administrator will make sure that all staff have current TB tests and or screenings each year and results placed in their chart. Staff member has scheduled his test for 1/11/2024 and one staff member is no longer employed as of 12/15/2023 for health reasons.
Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records, 2 of 3 records reviewed did not have current First Aid and CPR certifications. Evidence: Staff #2 and #3 certifications expired 4/2022 and 3/2022 respectively
Plan of Correction:	Administrator has scheduled First Aid and CPR training for all staff on 2/6/2024 with Abrial Training Center. Administrator will keep better notice on when certifications expire for all staff members.
Standard #:	22VAC40-73-550-F
Description:	Based on a review of staff records, all records reviewed did not have documentation of annual review of residents right and responsibilities. Evidence: Staff #1, #2 and #3 did not have a current signed a review of resident?s rights and responsibilities in their charts.
Plan of Correction:	The Annual Review of Residents Rights and Responsibilities will be reviewed with all residents and staff members each year by the Administrator. Staff and residents will sign and date and the review will be placed in the file.
Standard #:	22VAC40-73-830-G
Description:	Based on a review of resident's records, the facility did not provide establishment of resident council information to residents annually. Evidence; There was no documentation to reivew that residents were offered to establish a resident?s council each year.
Plan of Correction:	The Resident Council information will be discussed with all residents during the Living Room evening chat and documented with their signatures and dates. The residents will create officers to preside.