VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Barrington at Hioaks
350 Hioaks Road
Richmond, VA 23225
(804) 320-1412

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: Feb. 21, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/21/23 10:30 a- 12:00 Noon The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection Number of. records reviewed:1 Observations by licensing inspector: Updates and renovations A complaint was received by VDSS Division of Licensing on 2-14-23 regarding allegations in the areas of: Resident Care and Related Service and Staffing and Supervision The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint 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 Yvonne Randolph, Licensing Inspector at (804) 662-7454 or by email at yvonne.randolph@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on an inspection at the facility on 2/21/22 to investigate an allegation of a resident fall, the facility failed to report to the regional licensing office an incident that negatively affected the health, safety or welfare of a resident within 24 hours. Evidence: Progress notes on 12/12/23 for resident # 1 documented ? resident is at hospital because of a fall?. An incident report was not received by the Department regarding the fall.
Plan of Correction:	The Clinical Director or Designee will conduct all staff in-service for fall protocol. Staff must notify Executive Director and Director of Nursing or Designee of the fall and follow fall protocol per the in-service given.
Standard #:	22VAC40-73-680-H
Complaint related:	No
Description:	Based on a review of the medication administration records (MARs) for one resident, documentation, the administration of medications was inaccurately documented on the MAR for resident # 1 on 12/16/2023. Evidence: Staff # 1 documented the administration of Levothyrodine 25 mg tab and the placement of Ted Hose on 12-16-22. It was confirmed during an inspection at the facility that resident # 1 was admitted to the hospital on 12/12/22 and died at the hospital on 12/14/22.
Plan of Correction:	The Clinical Director or Designee will conduct all staff in-service on procedures on holding medication when it is appropriate to prevent documenting medication that was not given. Procedure written to aid staff' understanding of issue.