VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hall's Care Homes, LLC S.
6520 Licking Creek Drive
Chesterfield, VA 23832
(804) 439-3472

Current Inspector: Tamara Watkins (804) 662-7422

Inspection Date: Jan. 9, 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 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 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

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: 1/9/2024 1:00p ? 2:30p. 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: 7 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: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: Staff/resident interactions, medications, menus, activities Additional Comments/Discussion: 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 Tamara Watkins, Licensing Inspector at (804) 662-7422 or by email at tamara.g.watkins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-160-A
Description:	Based on a review of staff records the facility failed to provide evidence of 20 hours of annual training for the administrator. Evidence: The last documented annual training hours in the record for Staff #1 is dated 3/22/22.
Plan of Correction:	Plan of Correction: Administrator will ensure all training has been completed and filed accordingly.
Standard #:	22VAC40-73-210-B
Description:	Based on a review of staff records the facility failed to provide evidence of 18 hours of annual training for direct care staff. Evidence: Staff #2 is a direct care staff and there are no documented annual training hours in her record.
Plan of Correction:	Administrator will ensure all staff has completed a refresher course as well as annual training. Once this has been completed, documentation will be filed accordingly.
Standard #:	22VAC40-73-440-A
Description:	Based on a review of resident records the facility failed to complete a uniform assessment instrument at least annually and whenever there is a significant change in the resident?s condition. Evidence: The last UAI completed and reviewed in the record for resident #2 is dated 10/18/22; and for resident #4 11/1/22.
Plan of Correction:	Plan of correction: Administrator will review and update all residents UAI?s. Once completed, all documentation will be filed accordingly.
Standard #:	22VAC40-73-440-F
Description:	Based on a review of resident records the facility failed to complete an individualized service plan every 12 months and as needed for a significant change of a resident?s condition. Evidence: The last ISP completed and reviewed in the record for resident #1 is dated 8/1/21.
Plan of Correction:	Administrator will review and update all residents UAI?s. Once completed, all documentation will be filed accordingly.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of resident records the facility failed to provide evidence of an annual review of the rights and responsibilities of residents in an assisted living facility with each resident and staff. Evidence: The last evidence of an annual rights review in the record for resident #4 is dated 11/10/22 and for staff #1 is dated 3/22/22.
Plan of Correction:	All residents record of rights and responsibilities will be reviewed by the residents and the administrator, once completed they will be documented and filed.
Standard #:	22VAC40-73-580-A
Description:	Based on a review of documentation the facility failed to provide evidence of an annual health inspection report. Evidence: Staff #2 was unable to provide a current facility health inspection report.
Plan of Correction:	Based on the size of the facility annual environmental health inspections are not required.