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: April 7, 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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced monitoring inspection was conducted by two Licensing Inspectors (LI) on 04-07-2022 from 8:30 AM to 11:22 AM. There were 3 residents in care at the time of the inspection. A tour of the facility was conducted, breakfast meal observed, medication cart inspected, and first aid kit reviewed. There have not been any new hires since the last inspection. LIs reviewed 3 staff records and 3 resident records. All morning medications were administered prior to the start of the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. The areas of noncompliance were discussed with the Administrator throughout the inspection and during the exit interview.

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on record review and interview, the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff attend at least 18 hours of training annually. Evidence: 1. The records for Staff #1, Staff #2, and Staff #3 did not have any documentation of training annually. 2. Staff #1 and Staff #2 also do not have documentation of continuing education required by the Virginia Board of Nursing for medication aides. 3. Staff #1 acknowledged Staff #1, Staff #2, and Staff #3 do not have any documentation of training annually.
Plan of Correction:	The administrator will ensure that all staff must meet the training requirements to include the number of hours and special training annually.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #3 works as direct care staff and does not have a current certification in first aid.
Plan of Correction:	The administrator will ensure that all staff must have updated CPR/First aid training with a qualified training agency.
Standard #:	22VAC40-73-310-H
Description:	Based on record review and interview, the facility admitted and retained individuals with prohibited conditions or care needs. Evidence: 1. Resident #2 admitted to the facility on 05-25-2021. The physical examination and report for Resident #2 (dated on 5/14/21) indicates the resident has gastric tubes and states the resident is not capable of independently feeding themselves and caring for the tube. 2. The disclosure statement signed by the POA for Resident #2 under the criteria for admission to the facility and restrictions on admission states ?no peg tube, sores, combative residents.? 3. Staff #1 acknowledged Resident #2 admitted and continues to remain at the facility with a gastric tube that Resident #2 is not capable of independently feeding themselves and caring for the tube.
Plan of Correction:	The administrator will ensure to screen the resident prior to admission. Regulation restrictions must be observed and followed at all times.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the resident?s identified needs based on the Uniform Assessment Instrument (UAI). Evidence: 1. Resident #1?s ISP does not include date outcome achieved for the identified needs. 2. Resident #2?s UAI (dated 5/10/21) states the resident requires mechanical and physical assistance with bathing, dressing, toileting, transferring, wheeling, and mobility as well as requires assistance with housekeeping, laundry, and money management; however, Resident #2?s ISP (dated 6/20/21) does not address these identified needs based on the UAI. For the items identified on Resident #2?s ISP, it does not include the date identified for the needs listed; however, the date outcomes achieved are dated 6/20/21.
Plan of Correction:	The administrator will ensure that the identified needs of the resident based on the UAI must be properly documented in the ISP.
Standard #:	22VAC40-73-470-E
Description:	Based on record review and interview, the facility failed to ensure registered medication aides (RMAs) be prohibited from administering medications via gastric tubes and medications may only be administered by licensed personnel (e.g., a licensed practical nurse (LPN) or RN). Evidence: 1. Resident #2 admitted to the facility on 05-25-2021 with a gastric tube. Based on the resident record and March MAR, RMAs are providing gastric tube care, medication administration, and feedings. The facility does not employ a licensed practical nurse or RN. 2. Staff #1 acknowledged RMAs provide medication administration for Resident #2 via gastric tubes.
Plan of Correction:	The administrator will ensure that RMAs are not allowed to administer medications and provide care to a resident with gastric tube.
Standard #:	22VAC40-73-610-B
Description:	Based on observation, the facility failed to post the menus for meals and snacks for the current week in an area conspicuous to residents. Evidence: 1. A menu posted for April 5, 2022 was posted in the dining room. There was also a menu for a week to include the menus for meals and snacks; however, it did not indicate the current month or day.
Plan of Correction:	The administrator will ensure that the current menus for the week must be posted properly for the residents.
Standard #:	22VAC40-73-660-A
Description:	Based on observation and interview, the facility failed to medications be in a locked area. Evidence: 1. While touring the facility on 4/9/22, medications were observed on a bedside table in a licensed bedroom of the facility. The room was unoccupied by a resident; however, the room and its contents were accessible to residents in the facility. 2. Staff #1 and Staff #2 acknowledged the medications were on a bedside table in a licensed bedroom of the facility.
Plan of Correction:	The administrator will ensure that no loose medications are inside the facility. Medications must be restored and kept inside the locked medication cart.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. Resident #2?s medication order for Carvedilol 3.125 mg tablet included a parameter that states hold if SBP <110, HR <60; however, there is no evidence that the resident?s blood pressure or heart rate was taken prior to the administration of the medication. 2. Staff #1 acknowledged the physician?s or other prescriber?s instructions on the aforementioned medications that were not reflected on the MAR.
Plan of Correction:	The administrator will ensure that the resident's medications shall be aministered in accordance with the physician's order and to gather all the data that needs to be monitored.
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to ensure the interior and exterior of all buildings be maintained in good repair and kept clean and free of rubbish. Evidence: 1. The outdoor deck has uneven boards and raised nail heads. The yard is scattered with items not currently in use such as clothing racks and gas cans. 2. Inside the facility, there is a grey substance in the hallway ceiling vent. Additionally, the shower floor in one of the rooms has peeling paint.
Plan of Correction:	The administrator will ensure to repair or replace the existing outside deck. A contract has been made to replace the shower tub and renovate the bathroom. The ceiling vent will be replaced. Gas can will and must be stored in appropriate storage.
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 a small flashlight and extra batteries. Two items were also noted as expired: antiseptic ointment expired 2/2021 and hand cleaner expired 10/2020.
Plan of Correction:	The administrator will ensure that the first aid kit must be properly organized and checked regularly. Outdated items must be removed and replaced.