VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Guardian Light, LLC
2101 Mountain Run Drive
Glen allen, VA 23060
(804) 261-5824

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: Jan. 22, 2024 , Jan. 23, 2024 and Jan. 31, 2024

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: 1-22-24 from 11:42 a.m.-11:46 a.m., 1-23-24 from 9:06 a.m.- 12:00 a.m., and 1-31-24 from 7:40 a.m.- 8:20 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: 1 Number of interviews conducted with staff: 1 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection 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 annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis 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 # 3 (hire date: 5-1-08) contained a TB screening last dated 11-11-22.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-280-D
Description:	Based on observation the facility failed to ensure that at least one direct care staff member shall be awake and on duty at all times in each building when at least one resident is present. Evidence: On 1-22-24 at approximately 10:00 a.m, the licensing inspector arrived at the facility and one resident was present but there was no staff member at the facility. During a phone call with the administrator, the administrator stated that she had left the facility to take another resident to day support. The licensing inspector returned to the facility at approximately 11:40 a.m. to confirm that the administrator was there with the resident.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-A
Description:	Based on a review of resident records the facility failed to ensure that the resident?s physical examination shall contain the results of a risk assessment documenting the absence 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 Resident # 3 (admit date: 12-11-23) contained a TB screening dated 12-8-23 noting that a TB skin test was read but did not indicate the results.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-350-B
Description:	The assisted living facility shall ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall document in the resident's record that this was ascertained and the date the information was obtained. Evidence: -The record for Resident # 3 (admit date: 12-11-23) contained a form that was not from the Virginia State Police with search results dated 1-17-24. -The record for Resident # 4 (admit date: 9-1-23) contained a form that was not from the Virginia State Police with search results dated 1-17-24.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-E
Description:	Based on a review of resident records the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: -The record for Resident # 3 (admit date: 12-11-23) contained an ISP dated 12-26-23 that was not signed or dated by the resident or his/her legal representative. - The record for Resident # 4 (admit date: 9-1-23) contained an ISP dated 8-2-23 that was not signed or dated by the resident or his/her legal representative.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-550-F
Description:	Based on observation during a tour of the facility the facility failed to ensure that the rights and responsibilities of residents shall be printed in at least 14-point type and posteconspicuously in a public place in all assisted living facilities. The facility shall also post the name and telephone number of the appropriate regional licensing supervisor of the department, the Adult Protective Services' toll-free telephone number, the toll-free telephone number of the Virginia Long-Term Care Ombudsman Program and any substate(i.e., local) ombudsman program serving the area, and the toll-free telephone number of the disAbility Law Center of Virginia. Evidence: During a tour of the facility with the administrator, the licensing inspector observed that the rights and responsibilities of residents were not posted.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 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: 12-1-22) contained a review of the rights and responsibilities of residents in assisted living facilities last dated 12-5-22. -The record for Staff # 1 (hire date: 5-1-08) contained a review of the rights and responsibilities of residents in assisted living facilities last dated 1-27-19. - The record for Staff # 2(hire date: 4-1-15) contained a review of the rights and responsibilities of residents in assisted living facilities last dated 12-27-22. -The record for Staff # 3 (hire date: 5-1-08) did not contain documentation of a review of the rights and responsibilities of residents in assisted living facilities.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-650-E
Description:	Based on a review of resident records the facility failed to ensure that 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 records for 2 of 2 residents observed during medication pass did not contain signed physician?s orders.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-950-E
Description:	Based on a review of facility documentation and an interview with the administrator, the facility failed to ensure that it 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 administrator provided documentation of the facility?s last review of emergency preparedness that was dated 5-20-22.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-980-A
Description:	Based on a review of the facility?s first aid kit with the administrator, the facility failed to ensure that the first aid kit contained all required items. Evidence: The first aid kit did not contain roller gauze or antiseptic ointment.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-980-C
Description:	Based on an interview with the administrator the facility failed to ensure that the first aid kit shall be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence: The facility did not have documentation to indicate that the first aid kit is checked monthly and the administrator was not certain when it was last checked.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-990-C
Description:	Based on a review of facility documentation and 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 facility?s last documented practice exercise for a resident emergency was dated 5-21-23.
Plan of Correction:	Not available online. Contact Inspector for more information.