VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Covenant Columns at Tapp
9078 Cudlipp Avenue
Mechanicsville, VA 23116
(804) 690-0570

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: March 5, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 2VAC40-73 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

Comments:

Type of inspection: Renewal Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 3/5/2024 12 to 2:30 p The Acknowledgement of Inspection form was emailed for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 5 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: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Facility maintenance and cleanliness, required postings, file documentation, staff/resident interaction, medication storage, resident bedrooms 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 Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-310-D
Description:	Based on file resident reviews, the assisted living facility administrator did not provide written assurance that the facility has the appropriate license to meet his care needs at the time of admission to two residents.
Plan of Correction:	Evidence: A written assurance was not found in the file for residents # 3 and # 4. Written assurance will be added to the resident agreement or resident disclosure document templates
Standard #:	22VAC40-73-450-C
Description:	Based on resident file reviews, the individualized service plan for one resident did not include a description of identified needs and date identified based upon the fall risk rating.
Plan of Correction:	Evidence: Resident # 3 had a fall risk rating dated 11/21/23. The individualized service plan for the resident did not address fall risk. All residents ISPs will be reviewed and corrected with Fall Risk Assessment, as applicable
Standard #:	22VAC40-73-450-D
Description:	Based on resident file reviews, hospice services provided are not included on the individualized service plan for one resident.
Plan of Correction:	Evidence: Resident # 1 was admitted to hospice services on 1-23-23. Hospice services provided were not found on the individualized service plan for resident # 1. All residents ISPs will be reviewed and corrected with Hospice care, as applicable
Standard #:	22VAC40-73-720-A
Description:	Based on resident file reviews, a written Do Not Resuscitate order is not included in the individualized service plan for one resident.
Plan of Correction:	Evidence: A file review found that resident # 4 has a Do Not Resuscitate order that was not on the resident?s service plan. All residents ISPs will be reviewed and corrected with DNR orders, as applicable