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 18, 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

Technical Assistance:

22VAC40-73-870

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: 04/18/2023 from 8:30 am to 11:40 am. 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: 8 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 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 #:	22VAC40-73-320-B
Description:	Based on record review, the facility failed to annually complete a risk assessment for tuberculosis on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. The last TB risk assessment for Resident #2 (dated 10/26/22), Resident #3 (dated 1/16/23), and Resident #4 (dated 10/18/22) was not completed as they did not indicate a review of the risks or recommendation on if TB testing is indicated at this time.
Plan of Correction:	The administrator will ensure that the tuberculosis assessment of each resident and staff must be done completely, properly documented.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication. Evidence: 1. There were 5 prefilled syringes of Morphine Sulfate 20 mg/1 ml solution for Resident #1 expired 5/25/2022 observed on the medication cart.
Plan of Correction:	The administrator will ensure that expired medications and supplements must be discard properly to follow the medication disposal procedure.
Standard #:	22VAC40-73-660-A-2
Description:	Based on observation, the facility failed to keep schedule II drugs and any other drugs subject to abuse in a separate locked storage compartment (e.g., a locked cabinet within a locked storage area or a locked container within a locked cabinet or cart). Evidence: 1. There were 5 prefilled syringes of Morphine Sulfate 20 mg/1 ml solution and a bottle of Morphine Sulfate solution for Resident #1 in the medication cart; however, the items were not withing a separate locked storage compartment.
Plan of Correction:	The administrator will ensure that all controlled and schedule II drugs must be in a separate locked container in a locked cabinet all the time if not in used.
Standard #:	22VAC40-73-680-I
Description:	Based on record review, the facility failed to ensure the MAR include a prescribed medication for administration. Evidence: 1. Resident #3 received an order for a multivitamin to be administered once daily on 1/16/2023; however, the medication is not listed or documented as administered on the February 2023 and March 2023 MAR.
Plan of Correction:	The administrator will ensure that the prescribed medication and supplement by a physician must be properly documented in the MAR.
Standard #:	22VAC40-73-690-E
Description:	Based on record review, the facility failed to ensure the medication review include the items identified in the standard. Evidence: 1. The last medication review was completed on 1/27/23; however, the review indicates a med room/station inspection to include its general appearance and observations, medication cart review, controlled drugs review, emergency kit review, and refrigerator/freezer review. The report did not include a review of the following: all medications that the resident is taking and medications that he could be taking if needed (PRNs), an examination of the dosage, strength, route, how often, prescribed duration, and when the medication is taken, documentation of actual and consideration of potential interactions of drugs with one another, documentation of actual and consideration of potential interactions of drugs with foods or drinks, documentation of actual and consideration of potential negative effects of drugs resulting from a resident's medical condition other than the one the drug is treating, consideration of whether PRNs, if any, are still needed and if clarification regarding use is necessary, consideration of a gradual dose reduction of antipsychotic medications for those residents with a diagnosis of dementia and no diagnoses of a primary psychiatric disorder, consideration of whether the resident needs additional monitoring or testing, documentation of actual and consideration of potential adverse effects or unwanted side effects of specific medications, identification of that which may be questionable, such as (i) similar medications being taken, (ii) different medications being used to treat the same condition, (iii) what seems an excessive number of medications, and (iv) what seems an exceptionally high drug dosage, and the health care professional shall notify the resident's attending physician of any concerns or problems and document the notification.
Plan of Correction:	The administrator will ensure the medication review shall be performed every six months of all the medications of the residents. The administrator will get in touch with the physician and pharmacist to perform the review in accordance with the standard.
Standard #:	22VAC40-73-720-A
Description:	Based on record review, the facility failed to ensure the written Do Not Resuscitate (DNR) order is included in the resident?s individualized service plan. Evidence: 1. Resident #1, Resident #2, Resident #3, and Resident #4 have a valid DNR order in their resident records; however, the written order is not included in their individualized service plans.
Plan of Correction:	The administrator will ensure that the Do Not Resuscitate (DNR) order must be documented in the resident care plan.