VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hanover Manor
809/811 Thompson Street
Ashland, VA 23005
(804) 368-0110

Current Inspector: Kimberly Davis (804) 356-3572

Inspection Date: March 7, 2025

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

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3-7-25 from 10:05 a.m.-3:00 p.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: 65 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 interviews conducted with residents: 3 Number of staff records reviewed: 3 Number of interviews conducted with staff: 2 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection- facility documentation, facility postings, first aid kit, medication pass, physician?s orders, medication administration records. 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 #:	22VAC40-73-1110-B
Description:	Based on a review of resident records the facility failed to ensure that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident's continued residence in the special care unit. Evidence: -The record for memory care Resident # 1 (admit date: 1-12-23) contained an annual review of the appropriateness of the resident's continued residence in the special care unit last dated 1-12-24. -The record for memory care Resident # 2 (admit date: 11-20-23) did not contain a six month review or an annual review of the appropriateness of the resident?s continued residence in the special care unit as confirmed by staff.
Plan of Correction:	The reviews of the appropriateness of the resident's continued residence in the special care unit were completed for the two residents listed on 3/10/25. POAs have been contacted and asked to sign document by 3/21/25. Monthly audits will be performed by DON and Memory Care Coordinator to ensure all six month and annual reviews of the appropriateness of the resident's continued residence in the special care unit are completed for all residents.
Standard #:	22VAC40-73-440-D
Description:	Based on a review of resident records the facility failed to ensure that for private pay individuals, the assisted living facility shall ensure that the uniform assessment instrument (UAI) is completed as required by 22VAC30- 110. Evidence: The record for Resident # 3 (admit date: 11-20-23) contained a UAI dated 11-20-24 that did not have the Psycho-Social Status /Behavior Pattern completed.
Plan of Correction:	The UAI was completed immediately after the inspection. Monthly audits will be performed by DON and Memory Care Coordinator to ensure that all UAls are completed appropriately.
Standard #:	22VAC40-73-680-D
Description:	Based on a review of resident records and a medication pass observation the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber?s instructions. Evidence: The record for Med Pass Resident # 1 contained a physician?s order and a medication administration record for Fluticasone 50mcg nasal spray for 8:00 a.m. However, the inspector observed that the medication was administered to the resident during the 12:00 p.m. med pass.
Plan of Correction:	Immediately after the inspection, counselingwas provided to the RMA that administered the medication regarding administering medications at the right time. DON and Memory Care Coordinator will have monthly meetings/in-service trainings with RMAs to go over proper medication administration.
Standard #:	22VAC40-73-950-E
Description:	Based on a review of facility documentation the facility failed to ensure a 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 facility was unable to provide documentation of a semi-annual review on the emergency preparedness and response plan for all staff and residents.
Plan of Correction:	Administrator and Director of Resident Services reviewed the emergency preparedness plan and response plan with residents on 3/10/25. Residents signed documentation that they understood the plan. Administrator and/or Director of Resident Services will review the emergency preparedness and response plan with all staff, residents and volunteers at least semi-annually going forward.