VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Pearl at Watkins Centre
650 Watkins Centre Parkway
Midlothian, VA 23112
(804) 893-0067

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: March 19, 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

Comments:

Type of inspection: Renewal Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 3/19/24, 9:30 a to 1:15 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: 32 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: medication administration, resident/staff interaction, required posting, visitor protocol, facility maintenance and cleanliness, lunch meal Additional Comments/Discussion: Administrator was on site 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 Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-110-1
Description:	Based on a review of background checks for all staff hired since 11/1/23, background checks did not meet the requirements specified in the Regulations for Background Checks for Assisted Living Facilities and Adult Day Care Centers (22VAC 40-90) Evidence: 1, Section 63.2-1720 of t he Code of Virginia requires all employees of assisted living facilities, as defined by ? 63.2-100 of the Code of Virginia, to obtain a criminal history record report from the Department of State Police. 2. Nine staff did not have a back ground check form the Department of State Police.
Plan of Correction:	Background checks as specified in regulations for background checks for Assisted Living and Adult Day Care Services; Background checks for new employees have been submitted through the Virginia State Police Registry on 03/19/2024, through a sister community, in Harrisonburg. Background checks had been ran through ?Checkr? a system used by our recruiting software.
Standard #:	22VAC40-73-940-A
Description:	Based on an interview, the facility did not comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: Staff # 4 reported that the facility did not have an annual fire inspection report.
Plan of Correction:	Annual Fire Inspection not available: We were unable to locate the current Chesterfield County inspection report. We were able to locate a third-party inspection that was used completed in September 2023. Fire Marshall is scheduled to complete the inspection on March 28, 2024.