VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Wybe & Marietje Kroontje Health Care Center
1000 Litton Lane
Blacksburg, VA 24060
(540) 953-3200

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: April 19, 2022

Complaint Related: No

Areas Reviewed:

AREAS OF STANDARDS ? 22VAC40-73 GENERAL PROVISIONS ? 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES ? 22VAC40-73 PERSONNEL ? 22VAC40-73 STAFFING AND SUPERVISION ? 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS ? 22VAC40-73 RESIDENT CARE AND RELATED SERVICES ? 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS ? 22VAC40-73 BUILDINGS AND GROUND ? 22VAC40-73 EMERGENCY PREPAREDNESS ? 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ? ARTICLE 1 ? SUBJECTIVITY ? 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS ? 63.2 GENERAL PROVISIONS ? 63.2 PROTECTION OF ADULTS AND REPORTING ? 63.2 LICENSURE AND REGISTRATION PROCEDURES ? 63.2 FACILITIES AND PROGRAMS ? 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES ? 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION ? 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT ? 22VAC40-80 THE LICENSE ? 22VAC40-80 THE LICENSING PROCESS ? 22VAC40-80 COMPLAINT INVESTIGATION ? 22VAC40-80 SANCTIONS Technical Assistance Provided: N/A Comments/Discussion: Type of inspection: Renewal inspection was conducted on 04/19/2022 and the inspector was on-site at the facility beginning at 9:45 am and concluded at 3:00pm day of the inspection. The Acknowledgement of Inspection form was signed and left at the facility for 04/19/2022. The evidence gathered during the inspection determined non-compliance with applicable standard or law, and violation were documented on the violation notice issued to the facility. 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 departments 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 Crystal B. Mullins, Licensing Inspector at (276) 608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-A
Description:	Based on observation, the facility failed to implement its infection control policy specifically with regard to utilizing blood glucose monitoring practices that are consistent with CDC recommendations. EVIDENCE: 1. While performing an audit of the Arbor medication cart at approximately 01:34 pm, the LI observed a blood glucose monitor which was found in a box belonging to Resident #12; however, the blood glucose monitor was not labeled with the resident?s name. 2. While performing a medication cart audit Resident #6 was found to have the container for the glucometer labeled, but the meter itself was not labeled with the Resident?s name. 3. While performing a medication cart audit Resident #9 was found to have bag for the glucometer labeled; but the back of the meter itself was not labeled with the Resident?s name
Plan of Correction:	The glucose monitors were not individually labeled. The container the meters were held in, were labeled. However, the meters were also labeled the day of the survey. The labels on both the containers and the meters will be maintained. The labels will be checked via the day and night shift daily task list to ensure compliance starting 4/20/22. [sic]
Standard #:	22VAC40-73-350-B
Description:	Based on review of resident records, the facility failed to ensure that the assisted living facility obtained prior to admission whether a potential resident is a registered sex offender. EVIDENCE: 1.Resident #10 was admitted the facility on 02/16/2022. The file did not contain documentation that the facility had checked the sex offender registry for this resident?s name.
Plan of Correction:	The sex offender record for one of twelve residents was unable to be located in the business file. The sex offender record was printed and filed in the resident record during the survey. The admission paperwork cannot be recreated. However, the chart is now complete. The Administrator will continue to check behind each Admission to confirm the existence of the sex offender record. The Education Department will audit 50% of the new admissions for the next 3 months to ensure compliance. A 100% compliance rate is expected. [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on record review, the facility failed to implement its medication management plan, specifically as it relates to methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes. EVIDENCE: 1. The facility?s medication management plan effective 2018, states ?The count of controlled substances is documented in the narcotics book and both staff will sign that the count was completed and document any discrepancies?. 2. While performing an audit of two of the facility?s medication carts, the LI and Staff #4 reviewed theBased on record review, the facility failed to implement its medication management plan, specifically as it relates to methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes. EVIDENCE: 1. The facility?s medication management plan effective 2018, states ?The count of controlled substances is documented in the narcotics book and both staff will sign that the count was completed and document any discrepancies?. 2. While performing an audit of two of the facility?s medication carts, the LI and Staff #4 reviewed the controlled drug books for the safe secure unit (the Arbor) and the Hall 1 cart while also comparing those books to random samples of narcotics in their respective carts. 3. The Arbor cart contained the controlled medication Hydrocodone-APAP 5-325 MG for Resident #11 to take 1 tab by mouth 3 times daily and every 4 hours as needed for pain. When LI and Staff #4 compared the tablet count to the total on the controlled drug form, there were 23 tablets in the medicine dosing card. The controlled substance count form indicated that there were 24 tablets. Staff #4 indicated that she had forgotten to sign the form after giving the resident her scheduled 1:00 PM dose on 04/19/2022 and then staff 4 began updating the form prior to the LI obtaining a copy. 4. The medication cart for Hall 1 contained the controlled medication Lorazepam 0.5 MG tablet for Resident #8 to take 1/2 tablet (0.25 MG) by mouth 3 times a day for chronic anxiety. When the LI and Staff #4 compared the actual tablet count to the total on the controlled drug form, there were 17 tabs medicine dosing card; however, the form indicated that there were 18 tabs. Staff #4 indicated that she had forgotten to sign the form after giving the resident her scheduled 12:00 PM medication on 04/19/2022 and then Staff #4 began updating the form before the LI could obtain a copy.
Plan of Correction:	The medication management plan was not followed due to a controlled substance was not given correctly. This medication error cannot be corrected. All residents have the potential to be affected. The nurse involved in the medication error was removed from passing medications, re-education on medication administration and documentation and has received disciplinary action. Medication passes will be observed to ensure accurate narcotic counts. The Education Department will audit 10% of the medication passes with the expectation of 90% compliance each month for three months. [sic]
Standard #:	22VAC40-73-680-M
Description:	Based on observations made during the audit of the medication cart audit, the facility failed to have available all PRN (as needed) medications available, properly labeled for the specific resident, and properly stored at the facility. EVIDENCE: 1. Resident #4 has a physician?s order dated 03/24/2022 for Acetaminophen ER Cap 650mg, Tylenol Arthritis to administer one capsule by mouth one time daily as needed for pain (1-3). (Do not exceed APAP total daily dose greater than 3). 2. This medication was not available in the medication cart for Resident #4.
Plan of Correction:	All PRN medications for one resident were not available upon inspection. The medication was delivered for that resident that evening. A par level will be maintained on all PRN medications per resident so that a minimum number will be maintained. The Education department will educate the staff to reorder PRN medication prior to running out and allowing time for delivery. The Education department will audit PRN medications for re-order status each month for three months with the expectation of 90% compliance rate. [sic]
Standard #:	22VAC40-73-700-1
Description:	Based on observations made during review of resident records, the facility failed to ensure all required items were documented on the physician?s or other prescriber?s order for one resident receiving oxygen. EVIDENCE: 1. Resident #4 has a physician?s order dated for 02/03/2022 for Oxygen at 2 Liters per minute via nasal cannula as needed to be used to keep Oxygen saturation level above 90%. This order did not contain the source of oxygen such as compressed gas or concentrator.
Plan of Correction:	Doctor?s orders were not documented fully. The order did not contain the source of O2 (portable tank or concentrator). The order was corrected the day of the survey. The nurses will be educated to the correct procedure for O2 orders. O2 orders will be audited by the Education Department monthly for 3 months with the expectation of a 90% compliance rate.
Standard #:	22VAC40-73-870-A
Description:	Based on observation made during the tour of building, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. While LI was waking about the facility, at approximately 10:09 am, the LI observed a large purple stain on the carpet outside of Resident room #107. 2. At approximately 10:29 am, the LI observed a horizontal black mark along the dining room wall in the facility?s safe secure unit.
Plan of Correction:	A stain was found on the carpet and scuff marks were found on the wall. The stain, from earlier that day, was removed that day. The scuff marks were painted. The facility will be kept clean and neat for all residents. The Director of Housekeeping will make rounds and supervise the staff to ensure the facility is kept clean. Facility walk-thrus will be completed and reported to QAA on a quarterly basis to ensure compliance for the next two quarters. A 90% compliance rating will be acceptable. [sic]