VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lake Prince Woods
100 Anna Goode Way
Suffolk, VA 23434
(757) 923-5500

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Aug. 23, 2022

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 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/23/2022 from 8:55 am to 3:20 pm. 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: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 4 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on record review, the facility failed to ensure prior to admission to a safe, secure environment, residents have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Resident #2 admitted to the safe, secure environment on 06/08/2021; however, there is not an assessment of serious cognitive impairment completed in the resident?s record.
Plan of Correction:	On 8/25/22, the Clinical Coordinator reviewed all current resident?s records for the need of an ?assessment by independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare?. The Clinical Coordinator will complete the chart audit to ensure to ensure all paperwork is present on all current resident?s charts. When items are found missing, the document (s) will be replaced if possible and if not, a MISSING ITEM form will be placed in the chart to acknowledge the missing documentation.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the comprehensive individualized service plan be completed within 30 days after admission and include the required items listed in the standard. Evidence: 1. The most current ISP in the record for Resident #2 was completed by the facility on 6/8/21. Several of the identified needs such as transferring, dressing, assistance with oral care, etc. on the 6/8/21 ISP indicated the date of the expected outcomes/goals as 12/12/2021. 2. Resident #3 admitted to the facility on 01/27/2022; however, there was not a comprehensive ISP in their resident record.
Plan of Correction:	On 8/25/22 the AL Director updated residents #2 & #3?s UAI?s & ISP?s to reflect accurate and correct information is on each resident?s ISP based off information from the UAI. On 8.25/22 the AL Director placed Resident #3?s ISP into her chart. All UAI?s & ISP?s are currently being audited and verified for accuracy. All updated UAI?s and ISP?s copies are kept in each resident?s chart and in a binder kept by the AL Director.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to ensure their written plan for medication management includes methods to prevent the use of outdated medications. Evidence: 1. The following expired medications were observed in the medication carts at the facility: Acetaminophen 500 mg caplets expired 11/2015 for Resident #5 and Vitamin D2 25mg softgels expired 10/2020 for Resident #8.
Plan of Correction:	The AL Director reviewed the facility?s Medication Management Plan with all staff on 8/25/22. Staff responsible for each medication cart has completed the Cart Audit for expired medications. Staff will audit each medication cart twice monthly to ensure all expired medications (including the over-the-counter meds) are removed timely. The cart audits will be given to the Clinical Coordinator for review.
Standard #:	22VAC40-73-980-A
Description:	Based on observation, the facility failed to ensure a first aid kit for the building contain items as identified in the standard. Evidence: 1. The building first aid kit did not include scissors and contained expired antiseptic ointment (expired 11/2021).
Plan of Correction:	On 8/25/22, the AL Director inspected all first aid kits maintained by AL to ensure all items identified in the standard were present and all expired items were removed. The First Aid Kit audit will be completed twice monthly for all first aid kits to ensure all items are present and items with expired dates are removed from the first aid kits prior to the expiration dates. This audit will be forwarded to the Clinical Coordinator for review.