VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Williams Luv N Care Home
4012 Elmswell Drive
Richmond, VA 23223
(804) 222-4752

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: Dec. 4, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS

Comments:

An unannounced inspection was conducted at the facility on 12/4/2019 from approximately 10 am to 2:00 pm by four licensing representatives and two local adult protective services staff members to investigate an allegation regarding resident care, staffing and a resident emergency. The complaint was determined to be valid. During the inspection other areas of noncompliance were found and cited unrelated to the allegation. Please complete the "plan of correction" and "date to be corrected" for the violation cited on the violation notice and return to the Inspector within 10 days. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the non-compliance with the standard, 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). See violation notice for non-compliance. The provider's responses for the "plan of correction" were not received as of 2/4/2020 and will not appear on this "Violation Notice."

Violations:

Standard #:	22VAC40-73-50-A
Complaint related:	No
Description:	Based on a review of resident records, the facility failed to provide a current disclosure statement with information about the facility that contained all of the required components. Evidence (Resident #1): 1. The resident record contained three different versions of the Assisted Living Facility Disclosure Statement (ALFDS). The resident signed one of the three versions on 10/1/2019. The licensee signed the second version on the Resident/Guardian line on 10/1/19. The third version was located in the resident record although not signed and dated. 2. Two of the three disclosure statements under the ownership structure of the facility were blank. 3. One of the three disclosure statements for the amount of base fee notes - "Owner will decide at interview". A second disclosure statement lists - Public Pay at 1223.00. The Public Pay Auxiliary Grant rate at the signing of the ALFDS was 1317.00 as evidenced by a letter dated June 4, 2019 from Department for Aging and Rehabilitative Services increasing the rate effective July 1, 2019. 4. There was no documentation in any the disclosure statements providing clear information about what is included in the base fee and fees for additional accommodations, services, and care. 5. One of the ALFDS being used by the facility is version dated 04/16. The other two versions were compared to the 04/16 version found in the resident record and were determined to be the same version. The version of the ALFDS that should have been used at the time of the resident's admission is dated 02/19. 6. Two of the disclosure statements under criteria for admission to the facility and any restrictions on admission noted -Owner will decide at interview. 7. One of the three disclosure statements under criteria for discharge from the facility noted -Owner will decide as needed because each case is different. 8. Three of three disclosure statements did not contain categories of activities. Two of the three noted-"social workers and family are encourage to take residents out" and "social workers must take residents out for activities or family members". 9. Two of the three disclosure statements noted the number one (1) under functions of staff and qualifications of staff per shift. The current regulation requires position types of staff and no longer requires functions of staff. Two of the three disclosure statements noted the shifts as 12a-12p and 12p-12a while one noted the shifts as 7a-7p and 7p-7a. Two of the three noted the number one (1) under Total Number of Staff Per Shift and Number of Staff Providing Direct Care Per Shift and one noted 1 1/2, respectively. 10. One of the three disclosure statement did not contain documentation whether the facility maintains liability insurance per the Standards. 11. Three of the three disclosure statements did not contain a notation that additional information about the facility included in the resident agreement is available upon request. 12. One of the three disclosure statements did not contain the department's website address with a note that additional information about the facility may be obtained from the website. 13. Two of three versions of the ALFDS, regarding of number of activities provided for residents, is listed as 7; the third version listed the number of activities as 10. While these hours are listed in all three versions, they do not meet the minimum requirement of the Standard for 22-VAC 73-40-520-D of a minimum of 11 hours of scheduled activities per week.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-A
Complaint related:	No
Description:	Based on a review of the resident record, the facility failed to ensure that a physical exam was completed within 30-days preceding admission by an independent physician. Evidence: 1. The documented date of admission to the facility for resident #1 is 10/17/2019. 2. The Report of Resident Physical Examination in the resident record was dated 9/27/2019. 3. The physician listed on Report of Resident Physical Examination could not be verified as a licensed physician in the Commonwealth of Virginia. The Department of Health Professions website returned a response,"Sorry, no matches were found." No names matching the name was listed. The Virginia Board of Medicine Practitioner Information website was also searched by a licensing representative and yielded no results of a physician with the same name. 4. The contact number for the individual listed as the physician on the Report of Resident of Physical Examination was called multiple times by two licensing representatives in an attempt to verify the physician's practice. The phone rang each time called and no voicemail was available. 5. The Standards for Licensed Assisted Living Facilities define Physician as an individual licensed to practice medicine or osteopathic medicine in any of the 50 states or the District of Columbia. 6. The line on the Report noting the name of Designee, if applicable, had the name of the licensee of the facility written on it and not the name of a physician designee.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-380-A
Complaint related:	No
Description:	Based on a review of a resident record, the facility failed to ensure that prior to or at the time of admission, all of the personal and social information on the resident as required by the standard was obtained. Evidence (Resident #1): 1. The last home address, and address from which resident was received, is listed as the facility address. However, the address from which the resident was received was a skilled nursing facility (SNF) as evidenced by the SNF discharge documentation. 2. Discharge documentation from the skilled nursing facility (SNF) indicates that the resident was discharged from the SNF on 10/17/2019. The date of admission listed on the Participant Record, a VDSS Model Form for ADCC (Adult Day Care Center), was 10/1/2019. Admission is defined by the Standards for Licensed Assisted Living Facilities as the date a person actually becomes a resident of the assisted living facility and is physically present at the facility. 3. The birth date listed in the resident record (07/15/1943) does not match the birthdate on the Virginia Uniform Assessment Instrument Part A and Part B (07/15/1932) or the Medicaid Funded Long-Term Care Service Authorization Form (07/15/1932), both dated 9/16/2019 and completed by a screener while the resident was in the hospital. 4. The Home Health Care Consent form obtained during the inspection dated 11/01/2019 was signed by the licensee followed by the letters POA handwritten beside her name. The Durable Power of Attorney line is circled "yes". The line on the form, If yes, who is the agent, contained the name of the licensee. Copies of legal documents that show proof of the authority of the licensee to act on behalf of the resident were not in the resident record. 5. The name, address, and telephone number of personal physician was not complete. The address lists only a street name, but no specific street address. Verification of this physician could not be determined. No first name of the physician was listed on the form. The Department of Health Professions license look-up website does not contain any licensed physicians practicing in the zip code listed in the resident record with the same last name. The phone number listed in the resident record rings when called but there was no answer and no voicemail.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-390-A
Complaint related:	No
Description:	Based on a review of the resident record, the facility failed to ensure that at or prior to the time of admission there was a written agreement/acknowledgment that contained all of the required components. Evidence (Resident #1): 1. Listing of specific charges for accommodations, services, and care. The Resident Agreement under number one "1" notes $3000.00 per month for private pay. The Monthly Financial work sheet found in the resident record notes "Room & Board at $1300.00? 2. The copy of the Resident Agreement dated 10/1/2019 obtained during the inspection did not contain a refund policy to apply when transfer of ownership, closing of the facility, or resident transfer or discharge occurs. 3. There was no documentation referencing requirements or rules to be imposed regarding resident conduct and other restrictions or special conditions in the Resident Agreement. 4. There was no specific acknowledgements referencing: (a) the rules of conduct and other restrictions or special conditions; (b) that the resident or his legal representative has been informed of the policy regarding the amount of notice required when a resident wishes to move from the facility; (c) the policy required by 22 VAC 40-73-840 regarding pets living in the facility; (d) that the resident or his legal representative or responsible individual has been informed of the facility's policies and procedures for implementing rights and responsibilities of residents of assisted living facilities; (e) that the resident has been informed and had explained to him that he may refuse release of information regarding personal affairs; (f) that the resident has been informed that interested residents may establish and maintain a resident council; (g) that the resident has been informed of the policy or guidelines regarding visiting in the facility; (h) that the resident has been informed of the rules and restrictions regarding smoking on the premises, (i) that the resident has been informed of the policy regarding the administration and storage of medications and dietary supplements; (j) or that the resident has been notified in writing whether or not the facility maintains liability insurance.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-D
Complaint related:	No
Description:	Based on a review of resident records, the facility failed to ensure that the uniform assessment instrument (UAI) was completed as required by 22 VAC 30-110. Evidence (Resident #1): 1. The Virginia Uniform Assessment Instrument For Private Pay Residents of Assisted Living Facilities was completed on 9/30/2019 by staff members #1 and #2. 2. The Social Security Number for Resident #1 listed on the UAI does not match the Social Security Number on the Home Health Care Consent form dated 11/1/2019 nor the Virginia Uniform Assessment Instrument Part A and Part B and the Medicaid Funded Long-Term Care Service Authorization Form both dated 9/16/2019 and completed while the resident was still in the hospital. 3. The date of birth for resident #1 listed on the Virginia Uniform Assessment Instrument For Private Pay Residents of Assisted Living Facilities does not match the date of birth on the Virginia Uniform Assessment Instrument Part A and Part B, and the Medicaid Funded Long-Term Care Service Authorization Form both dated 9/16/2019 completed while the resident was in the hospital. 4. The Virginia Uniform Assessment Instrument For Private Pay Residents of Assisted Living Facilities completed prior to admission and while the resident # 1 was residing in a skilled nursing facility listed the current address of the resident as a facility address.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-750-E
Complaint related:	No
Description:	Based on observation, the facility failed to ensure that the residents had clean bed linen and pillows. Evidence: During a tour on 12/4/2019 of the physical plant with four licensing representatives, bed linen and pillows were found to be soiled and unclean in room # 2 where a resident resides as evidenced by the photographs taken.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-A
Complaint related:	No
Description:	Based on observation, the facility failed to ensure that the interior of the building shall be maintained in good repair. Evidence. 1. During a tour on 12/4/2019 of the physical plant, two licensing representatives observed that the baseboard and drywall was damaged on the bottom left wall entering the dining room on the first floor as evidenced by the photograph taken. 2. Room # 1, the only resident bedroom on the first floor, was found to have clothes scattered on the floors, beds, and dressers.
Plan of Correction:	Not available online. Contact Inspector for more information.