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: Jan. 29, 2020

Complaint Related: Yes

Areas Reviewed:

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 complaint inspection was completed at the facility on 1/29/2020 from approximately 9 am to 12 noon to investigate a concern regarding food supply and the cleanliness of the facility.The administrator/licensee was on site during the inspection. A determination of the validity of the allegations could not be made. Violations were found unrelated to the allegations. 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.

Violations:

Standard #:	22VAC40-73-40-B-4
Complaint related:	Yes
Description:	Based on observation, licensee and collateral interviews, and pursuant to ? 63.2-1712 of the Code of Virginia, the facility failed act in accordance with the General Procedures and Information for Licensure (22VAC40-80) to ensure that anyone that operates an assisted living facility does not make any report known to be false or untrue to any representative of the commissioner. Evidence: 1. A Report of Environmental Sanitation Inspection dated 11/8/2019 was received by the licensing inspector on 11/8/2019 from the licensee via email A copy of the same report was also received by the licensing administrator. 2. Subsequently, a report of Environmental Sanitation Inspection dated 11/8/2019 was received by the Department on 11/14/2019 from the Local Department of Health. 3. The report from the local Health Department did not match the report received by licensing from the licensee: (a) All handwritten notes that were on the report provided by the local Department of Health were not present on the report provided by the licensee; (b.) Section C: Food Service Operations, Food service operations are in compliance with The Commonwealth of Virginia Board of Health Food Regulations, was marked "N/A" on the report provided by the local Health Department and was marked "yes" on the report provided by the licensee; (c.) The section titled Summary and Recommendations: Additional health hazards observed, was not checked and included the handwritten comment "turtles found in the kitchen. I was told no one in the house handles them. Turtles in the food areas are not recommended." On the inspection form provided to the Department by the licensee, "no" was marked for additional hazards observed and there were no handwritten comments.. 4. The inspection report received from the licensee was forwarded to the representative of the local Department of Health who completed the health inspection on 11/8/2019 for review 5. An email dated 01/9/2020 from the representative of the local Department of Health stated "the attached report is not the same report I filled out on site on 11/8/2019 and gave to the owner...... My handwritten comments are not showing on this scanned document. Some of the boxes have been checked differently from my copy on file."
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-430-H-1
Complaint related:	No
Description:	Based on a review of discharge statements and an interview with staff # 1, the facility failed to maintain on file a discharge statement for one resident and to have an accurate discharge statement on file for one resident. Evidence: 1. Staff # 1 informed three licensing representatives that resident # 2 was discharged from the facility on 12/31/2019. The discharge statement provided by staff # 1 documented the date of discharge for resident # 2 as 12/31/2020 as evidenced by a photograph taken. 2. Staff # 1 informed the three licensing representatives that resident # 3 was discharged from the facility sometime in November 2019. Staff # 1 did not provide a discharge statement for the resident when requested.
Plan of Correction:	Administrator has doubled check all inactive files to make sure they were closed out properly. Corrections were made as needed. Administrator took class on how to close files. Class was helpful.
Standard #:	22VAC40-73-430-J
Complaint related:	No
Description:	Based on a review of a check presented to licensing representatives by staff # 1 on 1/29/2020, the facility failed to return to the resident within 60 days of discharge money held in trust or custody of the facility. Evidence: Resident # 1 was discharged from the facility on 8/1/2018 according to staff # 1 and the discharge statement reviewed. Staff # 1 presented for review by licensing an auxiliary grant check dated 11/6/2019. The check was in the possession of staff # 1, was still in the sealed envelope and had not been returned to the resident or issuer as of 1/29/2020.
Plan of Correction:	Administrator will not keep the check and give to DSS for any reason. The check will be rejected from mailman to prevent lost of money to resident. All unopened checks was returned to DSS.
Standard #:	22VAC40-73-560-H
Complaint related:	No
Description:	Based on an interview with staff # 1 on 1/29/2020, the facility failed to maintain resident records for at least two years after the resident leaves the facility. Evidence: 1.Staff # 1 informed licensing staff that resident # 2 was discharged from the facility on 12/31/2019. When the record for resident # 2 was requested by licensing, staff # 1 stated she did not have the record as the record had been "shredded". 2. Staff # 1 informed licensing that resident # 3 was discharged sometime in November 2019. When the record for resident # 3 was requested by licensing, staff # 1 stated she did not have the record as the record had been "shredded".
Plan of Correction:	All records will be discarded for two years to be in compliance with DSS. Administrator took organizational class to learn how to properly file documents. The class was helpful.
Standard #:	22VAC40-73-660-A
Complaint related:	No
Description:	Based on an observation and inspection of the facility on 1/29/2020, two residents were permitted to keep medication in their room without a determination by the facility that out of sight and inaccessibility safeguards do not apply. Evidence: The facility did not have documentation of determination that out of sight and inaccessibility safeguards do not apply for the the residents in care. 1. During the inspection of the facility, licensing representative # 1 observed vapor rub sitting on nightstands of residents # 4 and # 5.. The vapor rub was unsecured and accessible to residents in care. 2. Biscody, Meformin, and Aspirin were observed sitting on a table in an unlocked office on the first floor of the facility.These medications were accessible to residents in care.
Plan of Correction:	Residents are not allowed to keep medications in sight. All medication is kept in a locked box to prevent harm from happening. Administrator held a training class with staff and residents to enforce the rule.
Standard #:	22VAC40-73-680-H
Complaint related:	No
Description:	Based on interviews with staff # 1 and residents # 6 and # 7 on 1/29/2020, the facility failed to maintain documentation on a medication administration record (MAR) of medications administered to residents. Evidence: 1. Staff # 1 stated to the licensing representatives that all of the residents in the facility self administer their medications and that she does not mainatin medication administration records on any residents. 2. Resident # 6 stated in an interview with licensing representative # 1 that he was on insulin and that facility staff administers hhis medication "some of the time". 3. Resident # 7 reported to licensing representative # 1 that he was unable to administer his own medications due to his health problems and that facility staff administer his medications.
Plan of Correction:	Resident # 6 has been relocated to another facility. Staff # 1 (administrator) will triple check all MARs to assure DSS everything will match from now on.
Standard #:	22VAC40-73-750-B
Complaint related:	No
Description:	Based on an observation and inspection of the facility on 1/29/2020, the bedroom of resident # 4 did not contain a comfortable mattress. Evidence: The mattress in the bedroom of resident # 4 was observed by licensing representative # 1 to have a sinkhole in it with exposed coils creating an uncomfortable surface for the resident to sleep on.
Plan of Correction:	Administrator brought a new bed for all residents.
Standard #:	22VAC40-73-860-I
Complaint related:	No
Description:	Based on an observation and inspection of the facility on 1/29/2020, the facility failed to store cleaning supplies and hazardous materials in a locked area. Evidence: During the inspection of the facility, licensing representative # 1 observed cleaning supplies (oven cleaner, oven cleaner and glass top cleaner) stored under the kitchen sink in an area that was unlocked and accessible to the residents in care.
Plan of Correction:	All cleaning supplies are now kept in office where the door is locked at all times. The kitchen door is also kept locked now.