VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Liza's Residential Care
5084 Langston Court
Virginia beach, VA 23464
(757) 495-9722

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

Inspection Date: Feb. 3, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 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

Technical Assistance:

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Comments:

An unannounced focus monitoring inspection was conducted from 7:10 a.m until 9:00,to follow-up on previous violations cited during the renewal inspection . The administrator was present. No new staff had been hired or new residents had been admitted . One resident had been discharged. Four residents were in care. Checked the medication cart and medication orders.Checked menus and the activity calendar. Interviewed residents. The first aid kit was also checked. Please complete the ?plan of correction? for each violation cited on the violation notice and return it to me within 10 calendar days from today on 2-23-20 You will need to specify how the violation will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must include: 1. steps to correct the noncompliance 2. measures to prevent reoccurrences 3. Person(s) responsible for implementing and monitoring each step of the corrective measures and / or the preventative measure

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on record review and interview the facility failed to ensure the 10/19 disclosure statement prepared and provided to the resident and his legal representative, if any, disclosed whether or not the facility had an onsite emergency electrical power source for the provision of electricity during an interruption of the normal electric power supply. If the facility does have an onsite emergency electrical power source, the statement must include: (i) the items for which the source will supply power and (ii) whether or not staff of the the facility have been trained to maintain and operate the power source. For the purposes of this subdivision, an onsite emergency electrical power supply shall include both permanent emergency electrical power sources and portable emergency electrical power sources, provided that such temporary electrical power supply source remains on the premises of the facility at all times. Written acknowledgement of the disclosure shall be evidenced by the signature or initials of the resident or his legal representative immediately following the onsite emergency electrical power source disclosure statement. Evidence 1. While reviewing the residents' records with staff #1, the inspector found none of the four residents or their legal representative had acknowledged review of the 10/19 disclosure form. 2. Staff #1, confirmed the 10/19 disclosure form had not been reviewed and signed by the residents or legal representative.
Plan of Correction:	The administrator will ensure that the new and latest disclosure statements must be prepared and provided to the residents and or their legal representative. It must be reviewed, signed and dated by the resident or legal representative. The facility had an automatic emergency generator that supply the whole load of the facility. Every Wednesday of the week it will start automatically for testing.
Standard #:	22VAC40-73-450-F
Description:	Based on observation, record review, and interview the facility failed to ensure the individualized service plans(ISP) of the residents were updated at least once every 12 months and as needs or the condition of the resident changed. The update shall be performed by qualified staff and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons. Evidence 1. While with staff #1 and #2, the inspector found resident #1's ISP had not been updated since 12-1-18. 2. Resident # 2's ISP dated 7-17-19, had not been updated to include the fall precautions and interventions, or the transfer assistance and re-positioning assistance observed while seated in a chair.
Plan of Correction:	The administrator will ensure that the ISP of each resident shall be updated yearly. Include also the necessary changes and needs of the resident. The fall risk precautions and intervention must be included.
Standard #:	22VAC40-73-520-A
Description:	Based on observation and interview the facility failed to ensure activities offered residents a varied mix of weekly activities including those that are physical; social; cognitive, intellectual, or creative; productive; sensory; reflective or contemplative; involve nature or the natural world; and weather permitting, outdoor activity . Any given activity may involve more than one of these. Community resources as well as facility resources may be used to provide activities. Evidence 1.The posted activity calendar did not list any outdoor or productive activity.. 2. Staff #2 confirmed the activity calendar did not include outdoor or productive activities.
Plan of Correction:	The administrator will ensure that the outdoor or productive activity must be included in the activity calendar. The whole calendar must be reviewed and updated.
Standard #:	22VAC40-73-520-I
Description:	Based on observation ,record review and interview the facility failed to ensure there was written schedule of activities that met the following criteria: The type and hour of the activity. Evidence 1. The activity calendar posted listed bible study as the only activity every Sunday but there was no tpye or time for the activity listed. 2. Staff #2 confirmed bible study was the only activity and there was no time or type of activity listed on the activity calendar.
Plan of Correction:	The administrator will ensure that every activity listed on the activity calendar shall have a certain time to be perform.
Standard #:	22VAC40-73-610-B
Description:	Based on record review and interview the facility failed to ensure any menu substitutions or additions to the menu were recorded on the posted menu. Evidence 1. Staff #2,stated the posted breakfast menu of "eggs, sausage, and cold cereal was served. During interview the inspector was told breakfast was cold cereal. The change had not been posted on the menu. 2. The posted morning snack was doughnuts .Staff #2 stated she gave the residents yogurt instead as there were not doughnuts available. The substitution was not recorded on the menu.
Plan of Correction:	The administrator will ensure that the menu will be reviewed and modified. Every foods served in every meals shall correspond to the listed menu for the day and if there is any changes shall be posted accordingly.
Standard #:	22VAC40-73-680-H
Description:	Based on record review and interview the facility failed to ensure at the time the medications were administered, a staff documented on the medication administration record (MAR). Evidence 1. At about 8:37 a.m. while reviewing the MAR with staff #2, the inspector observed resident #2's scheduled 7a.m. Vitamin D3, Celexa 20 mg, and Synthroid 100 mcg had not been charted. 2. Staff #2 questioned staff #3, about the medication administration in the presence of the inspector. 3. Staff #3 stated "I have given the medications but I forgot to chart them ."
Plan of Correction:	The administrator will ensure that the MAR must be signed properly after administering the medications to the resident. Double checked the MAR all the time.
Standard #:	22VAC40-73-870-E
Description:	Based on observation and interview the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, were in good repair and condition. Evidence 1. While touring the facility with staff #2, the inspector observed in the kitchen a broken Formica counter-top with jagged edges across from the table where the residents eat. 2. Staff #2 confirmed the counter top was broken and needed to be repaired.
Plan of Correction:	The administrator will ensure that the kitchen counter top must be replaced to maintain the cleanliness and safety of the residents.