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: Oct. 22, 2019 and 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

Comments:

Unannounced complaint inspections were conducted at the facility on 10/22/2019 from approximately 12:45 pm to 2:30 pm and 12/04/2019 from approximately 10:00 am to 2:00 pm to investigate allegations regarding resident care, resident supervision and medication administration. One allegation in the complaint was determined to be valid. Areas of non-compliance was also found and cited unrelated to the complaint. 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 #:	22VAC40-73-300-B
Complaint related:	No
Description:	Based on an interview with the licensee, the facility failed to ensure that a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings. Evidence: The licensing inspector requested to review the communication log on 10/22/2019 to read any documentation present regarding the resident # 1 being sent to the hospital on 9/19/2019. The licensee stated that she did not have a communication log.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-B
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 prior to admission by an independent physician and that the physical contained all of the required components of the standard. Evidence: 1. The documented date of admission to the facility for resident #1 is 08/01/2019. 2. The Report of Resident Physical Examination in the resident record was dated 7/23/2019 and did not contain a statement that specifies whether the individual is or is not capable of self-administering medications. 3. A non-dated signed letter with a heading of Medical Center A was located in the resident record stating that the resident was capable of self-administering medications. The licensure of the registered nurse that signed the letter could not be verified using the Virginia Department of Health Professions website or a search of the Medical Center A staff directory. 4. A licensing representative asked the licensee on 10/22/2019 to provide documentation on all residents that administer medication. The licensee provided to the licensing representative letters for residents #2-5 all stating that the residents could self-administer medications. 5. Resident #2 had a non-dated letter from Medical Center A. The licensure of the physician that signed the letter could not be verified using the Department of Health Professions website, the Board of Medicine Practitioner Information website, or a search of the Medical Center A staff directory. 6. Resident #3 had a non-dated letter from Medical Center B. The licensure of the physician that signed the letter could not be verified using the Department of Health Professions website, the Board of Medicine Practitioner Information website, or a search of the Bon Secours staff directory. 7. Resident #4 had a letter dated 03/06/2018 from Medical Center C. A licensing representative contacted the physician on 12/9/2019 to verify the authenticity of the letter. On January 13, 2020 the division of licensing received a letter from the physician stating that resident #4 had not been seen in his office since 2016, that resident #4 was seen by a different physician in that practice and that he had not written or signed any letters regarding resident #4. 8. Resident #5 had a non-dated letter from Medical Center D. A licensing representative contacted the physician on 12/5/2019 to verify the authenticity of the letter. The physician submitted the letter that was written for the resident on 6/25/2019 stating that the resident can manage his medications under their (facility) supervision and they will monitor for compliance. The letter obtained from the licensee upon request stated that the resident can now manage his own medications unless the staff feel he is no longer safe to do so.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-460-E
Complaint related:	No
Description:	Based on a review of the resident record and interview with the licensee, the facility failed to ensure that any notable change in a resident's condition, including illness, and any corresponding action taken is documented in the resident record. Evidence: 1. The licensing inspector reviewed the record on 10/22/2019 for Resident # 1. There was no documentation regarding the resident being transported to the hospital for chest pains on 9/19/2019. 2. Upon request from the licensing representative, the licensee stated that she did not have any nurses notes regrading the incident.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-H
Complaint related:	No
Description:	Based on interviews, the facility failed to ensure that at the time medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents. Evidence: 1. The licensee informed the licensing staff and two adult protective service workers on 12/4/2019 that resident # 1 self administers his medications. 2. A licensing representative interviewed resident # 1 on 12/4/2019 and asked who administers his medication. He responded, "they do" referring to the facility staff. 3. The licensing representatives informed the licensee as to what the resident had stated and she replied "Well we do it if the resident doesn't feel like it". A second licensing representative asked the licensee if she had a medication administration record for resident # 1 to show when the facility administered medications. She responded "I need to write it down even though we just do it when the resident doesn't want to?"
Plan of Correction:	Not available online. Contact Inspector for more information.