VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Azzie Manor
15611 Keelers Mill Road
Dewitt, VA 23840
(804) 469-3703

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: Dec. 6, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: The licensing inspector was on-site on December 06, 2024. The licensing inspector arrived at approximately 2:00 PM and conclude the inspection at approximately 3:20 PM. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on December 03, 2024, regarding allegations in the area(s) of: staff supervision and insufficient heat in the building The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 2 Observations by licensing inspector: The physical conditions of the building did not present health or safety concerns. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were related to staff supervision of residents. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-280-D
Complaint related:	No
Description:
Plan of Correction:	1. Staff Expectations and Responsibilities: All staff are expected to remain alert and attentive while on duty. Sleeping or any behavior that compromises resident care and safety is strictly prohibited. Staff will be reminded that they are paid hourly and are expected to uphold professional conduct at all times. 2. Break Policy Update: Staff breaks must be taken in designated areas only (hallway or other approved locations). The dining room is off-limits to all staff during the night shift unless explicitly required for resident care. 3. Monitoring and Accountability: A staff monitoring system has been implemented, including unannounced supervisory checks during all shifts. Staff caught violating policies (e.g., sleeping, being in prohibited areas, etc.) will face immediate disciplinary action, including write-ups or termination. 4. Training and Communication: Mandatory training sessions has been held for all staff to review updated facility policies and procedures. A written acknowledgment of understanding and compliance with these policies has been required from each staff member and added to their employee file. 5. Reporting and Notification Procedures: Staff must notify the assistant administrator and manager immediately if they feel too tired to perform their duties before the start of their shift. Any issues with the facility buzzer system or other safety devices must be reported to the assistant administrator and manager immediately. 6. Reinforcement of Policies: Effective immediately, any staff found with their head down, in the dining room with the door closed, or in their car during their shift will be disciplined per facility policy. Repeated offenses will result in termination. Implementation Timeline: Staff training and policy review was completed immediately after inspection. New monitoring protocols were take in effect immediately. Supervisory checks were begin immediately and occur at random intervals. Monitoring and Evaluation: The assistant administrator and manager will conduct weekly reviews of staff compliance and document findings. Reports will be reviewed with all staff monthly to address any ongoing concerns and to ensure the corrective actions are effective.