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: June 15, 2023

Complaint Related: No

Areas Reviewed:

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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/15/2023, 9:50am to 3:23pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 53 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) 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 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-650-A
Description:	Based on observations made during the noon medication pass, the facility failed to have a valid physician?s order prior to making a change to a medication, procedure, or treatment. EVIDENCE: 1. Resident #9 has a physician?s order signed on 06/02/2023 for Rivastigmine TD 4.6mg, administer one patch transdermal and change every 24 hours, rotate sites upper chest, back, shoulders (not to repeat same site within 14 days) for dementia. 2. The June 2023 MAR indicates the patch was administered on the following dates/sites: 06/01 and 06/13 site 16 (left abdomen area) 06/03 and 06/14 site 15 (right abdomen area) 06/05 and 06/09 site 14 (left back upper arm) 06/08 and 06/15 site 10 (left front upper arm)
Plan of Correction:	The facility failed to have a valid physician?s order prior to making a change to medication, procedure or treatment. The physician order for rotating the transdermal patch to different sites not to repeat within 14 days has been corrected and signed by Physician. New order discontinued rotating sites not to repeat within 14 days. The Director of Nursing will check all residents to see if transdermal patch orders need to be changed not to repeat sites within 14 days. The Education Department will monitor all transdermal patch orders and DON to be notified of any discrepancies. The expectation of 100% compliance each month for three months. [SIC]
Standard #:	22VAC40-73-860-G
Description:	Based on observations made during the tour of the building, the facility failed to ensure all hot water taps available to residents were maintained within a range of 105 degrees Fahrenheit to 120 degrees Fahrenheit. EVIDENCE: 1. The common bathrooms in the hallway across from the dining area did not have hot water to reach 105 degrees Fahrenheit. The bathroom on the right reached a maximum temperature of 89.9 degrees Fahrenheit and the bathroom on the left reached a maximum temperature of 91.0 degrees Fahrenheit.
Plan of Correction:	The hot water in both common bathrooms in the hallway across from the dining area failed to reach and maintain 105 degrees Fahrenheit. The hot water issue was correct and now consistently reads above 105 degrees and below 120 degrees Fahrenheit per regulations. The facility will be maintain hot water between 105 and 120 degrees Fahrenheit for all residents. The Director of Housekeeping will make rounds and supervise the staff to ensure the facility is maintaining proper water temperature. The Director of Housekeeping / designee will do monthly temperature checks and report to QAA on a monthly basis to ensure compliance for the next three months. A 100% compliance rating will be required. Any issues found to be fixed by Maintenance / designee. [SIC]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the tour of the building, the facility failed to maintain the interior and exterior of the building in good repair and kept clean and free of rubbish. EVIDENCE: 1. At the exit area to the courtyard on the safe/secure area there is a covered porch which had debris such as leaves and dirt found around the covered porch area, especially in the corner areas. A resident in the safe/secure unit brought this to the LI?s attention and was upset this area had collected debris.
Plan of Correction:	The exit area to the courtyard on the safe/secure area had debris such as leaves and dirt found around the covered porch area especially in the corners. The exit area where the debris was found has been cleaned up. 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 sitting areas outside are kept free of leaves. [SIC]
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during the tour of the building, the facility failed to keep all furnishings and equipment clean and in good repair and condition. EVIDENCE: 1. At the courtyard exit on the safe/secure unit there are two arm chairs and a table sitting near the door. Both chairs were found to be stained and have holes and tears on the arm rests.
Plan of Correction:	Two arm chairs at the courtyard exit on the safe/secure unit were found to be stained and have holes and tears on arm rest. Torn chairs have been removed from sitting area and replaced with different chairs for residents to use. The facility furniture will be kept clean and neat for all residents. The Director of Housekeeping will make rounds and supervise the staff to ensure the facility furniture remains clean and free of tears and holes. Facility walk-thru will be completed and reported to QAA on a monthly basis for the next three months to ensure compliance. A 100% compliance rating will be acceptable. [SIC]