VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Showalter Center
1060 Showalter Drive
Blacksburg, VA 24060
(540) 443-3427

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: April 17, 2025 and July 23, 2025

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 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: 04/17/2025, 12:00pm to 1:29pm and 07/23/2025, 11:46am to 12:12pm 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 03/31/2025 regarding allegations in the area(s) of: Personnel, resident care and related services Number of residents present at the facility at the beginning of the inspection: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Staff training records Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on a review or resident records and interviews with staff, the facility failed to ensure that individualized service plans shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. EVIDENCE: 1. The comprehensive individualized service plan (ISP) for resident #1 was completed 06/22/2022. 2. The record for resident #1 included a medical history & physical exam form, completed 06/26/2023. 3. The medical history & physical exam form completed 06/26/2023 included the following physician?s orders: a. Catheter change every month: 16 F 10cc balloon and b. May flush catheter with 60mL sterile water QID PRN. 4. The ISP for resident #1 was not updated to reflect the physician?s orders for catheter care note above. Staff #1 and staff #2 also confirmed the ISP was not updated.
Plan of Correction:	? A comprehensive audit of all residents currently receiving catheter care was completed on 7/28/25 to ensure ISPs are accurate, up-to-date, and reflective of all current physician orders. This audit was reviewed by the Quality Assurance and Risk Management Team. Follow-up audits will be conducted monthly for the next three (3) months to ensure continued compliance and to demonstrate our commitment to preventing future violations. ? Timeliness of ISP Updates: ISPs will be reviewed and updated promptly following any significant change in a resident?s condition or new physician orders. The Director of Nursing (DON) or designee will ensure all updates are completed in a timely manner and will monitor for compliance. ? Staff Training: All nursing and care planning staff will receive re-education regarding regulatory requirements for timely ISP updates. Ongoing refresher training will occur quarterly, with documentation maintained in personnel files. [SIC]