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: May 14, 2024 and May 15, 2024

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

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: 05/14/2024 from 8:05 am to 10:30 am and 05/15/2024 from 6:00 am to 6:15 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: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Breakfast was observed. A medication pass observation was completed for 2 residents. The following were reviewed: resident and staff records, medication cart, and water temperatures. 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 #4 was completed on 1/16/2023. There was an additional TB risk assessment in their record; however, it was not dated.
Plan of Correction:	The administrator will ensure that the TB assessment must be properly documented, signed and dated by a licensed physician.
Standard #:	22VAC40-73-325-B
Description:	Based on record review, the facility failed to ensure a fall risk rating is completed at least annually, when the condition of the resident changes, and after a fall. Evidence: 1. The fall risk ratings for Resident #1, Resident #2, and Resident #3 were not dated. 2. The last fall risk rating for Resident #4 was completed on 5/16/2020.
Plan of Correction:	The administrator will ensure that the fall assessment rating of each resident must be reviewed annually. Signed and dated.
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 was a bottle of Centrum multivitamin tablets for Resident #5 expired 03/2024 observed on the medication cart.
Plan of Correction:	The administrator will ensure to check the medication of the resident expiration date. Expired medications must be discard properly.
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 3/21/2024; 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 to have a medication review and each resident by a licensed healthcare professional. Based on 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 #2 and Resident #3 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 DNR order of the resident must be documented in their respective individualized service plans.