VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lakeside Senior Living ALF Operations LLC
2125 Hilliard Road
Richmond, VA 23228
(804) 266-9666

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: May 12, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5-12-2023, 9:53 ? 10:48 am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 3-07-2023 regarding allegations in the areas of Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 12 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-430-H-1
Description:	Based on record review and interview, the facility failed to ensure a dated discharge statement signed by the licensee or administrator contained the date on which the resident, his legal representative, or designated contact person was notified of the planned discharge and the name of the legal representative or designated contact person who was notified; and the date of the actual discharge from the facility. Evidence: Resident #1?s ?Discharge Notification and Statement? did not contain: The date or signature of the licensee or administrator; The date on which the resident, his legal representative, or designated contact person was notified of the planned discharge and the name of the legal representative or designated contact person who was notified; nor the date of the actual discharge from the facility.
Plan of Correction:	This resident is no longer in the facility. It is our standard process to have administrator date and sign discharge notification and statement. An audit is being completed to ensure that this is being done moving forward. It is our standard process to include date on which resident or legal rep/designated contact is notified as well as to include discharge date from facility. This is to be included in our audit.
Standard #:	22VAC40-73-580-B
Description:	Based on record review, the facility failed to ensure if a resident's individualized service plan [ISP], physical examination report, mental health status report, or any other document indicates that the resident has a psychiatric condition that contributes to self-isolation, a qualified mental health professional shall make a determination in writing whether the resident should have the option of having meals in his room. If the determination is made that the resident should not have this option, then the resident shall have his meals in the dining area. Evidence: 1. Resident #1?s ?Psychiatric Periodic Evaluation? dated 11-09-2022 documented the resident?s diagnoses as Depression, GAD (generalized anxiety disorder), and psychosis. 2. ?Interdisciplinary Progress Notes? dated 5-17-2022 documented ?Resident [#1] remains in [resident?s] room most of the time. Does not eat in the dining room. Resident appears depressed. Angry at times.?; however, there was no documentation in Resident #1?s record by a qualified mental health professional determining that the resident should have the option of having meals in the resident?s room.
Plan of Correction:	Resident #1 no longer resides at the AL. Other residents with psychiatric conditions that contributes to self-isolation are potentially at risk. A qualified mental health professional will evaluate this group of residents and determine in writing whether the resident should have the option should have the option of having meals in his room or should not have this option and should have meals in the dining area. The individualized service plan will be updated to reflect psychiatric condition that may lead to self-isolation. Staff will be educated on signs and symptoms of depression, psychosis an anxiety and educated to report these symptoms or changes in behavior to nursing. The mental health professional will also be educated on need to document meal area for those residents with psychiatric conditions that contribute to isolation. Residents will be reviewed minimally weekly and PRN for changes in behavior, socialization, etc. that could contribute to self-isolation and notify psychiatry for further evaluation.
Standard #:	22VAC40-73-860-I
Description:	Based on observation, record review and interview with staff, the facility failed to store cleaning supplies and other hazardous materials in a locked area. Evidence: Resident #1 admitted 7-28-2021. A ?Psychiatric Periodic Evaluation? dated 3-02-2023 documented the resident?s diagnoses as ?Depression, anxiety, and a history of psychosis.? A facsimile note to Resident #1?s physician documented on 3-01-2023, ?Resident [#1] attempted suicide yesterday by drinking chemicals.? ?Interdisciplinary Progress Notes? by Staff #1 following the 2-28-2023 incident involving Resident #1 documented, ?Called placed to hospital to check on status of resident. Told resident has been transferred to [hospital] ?Resident [#1] now has a PEG tube? willing to voluntarily accept psych care.? A facility tour on 5-12-2023 by the licensing inspector showed an unlocked door with accessible chemicals located in a housekeeping closet, as well as accessible chemicals in the laundry room unlocked and accessible to residents, both on the second floor of the facility. Photographic evidence was obtained.
Plan of Correction:	Resident #1 no longer resides at the AL. All other residents are at risk of potential exposure or ingestion of hazardous materials that are unlocked/unsecured. Maintenance has conducted a full audit of all utility doors on both ALF/SNF to ensure they are operate as designed, they are all operational. The utility doors have been secured. Staff have been educated throughout ALF as well as all housekeepers regarding ensuring all utility doors to include the housekeeping closet is never left unattended and always secured. The same education was provided regarding the laundry area. Rounds are being completed daily (M-F) and on weekends by medication technician to ensure staff compliance with education and security of cleaning supplies and hazardous materials.
Standard #:	22VAC40-73-860-J
Description:	Based on record review and interview with staff, the facility failed to ensure a resident may be permitted to keep his own cleaning supplies or other hazardous materials in an out-of-sight place in his room if the resident does not have a serious cognitive impairment. The cleaning supplies or other hazardous materials shall be stored so that they are not accessible to other residents. Evidence: ?Interdisciplinary Progress Notes? for Resident #1 dated 2-28-2023 documented, ?Received call from receptionist. Asked if we had @ [sic]resident by the name [Resident #1]. [Resident #1] has called 911? Resident [#1] found sitting in chair vomiting. Juice bottle found sitting by her chair [with a] strong odor. Smell of some type of chemical? Resident [#1] [was] asked if [resident] drank any from juice bottle, resident stated, ?I?m ready to be [with] the Lord?? Room checked [after] resident left. Multiple bottles of cleaning fluids found locked in wood box multiple suitcases. Most bottles wrapped as much as 2 inches thick [with] duct tape. 1 bottle of pine sol found open. Resident [#1] would not allow staff to go in [resident?s] room. Only came out for meds + immediately returned to room.? A previous note dated 2-06-2023 to the resident?s physician by Staff #1 documented, ?Off all psych meds. Very paranoid?? Staff #1 acknowledged staff had not been going in Resident #1?s room ?for months? and were not aware of chemicals present in the resident?s room. Photographic evidence obtained of accessible chemicals to resident as seen on 5-12-2023 during inspection, including bleach, detergent, stain lifter detergent, disinfectant cleaner, glass cleaner, and non-acid bathroom cleaner.
Plan of Correction:	Resident #1 no longer resides at the AL. All other residents are potentially at risk of cleaning supplies or hazardous materials that are not secured to prevent accessibility to other residents. A letter will be sent to families of ALF residents regarding not bringing personal cleaning products considered hazardous or poisonous into the residents as they are not authorized. Staff educated that if these chemicals are seen in the resident rooms, that they are to be removed immediately for resident safety. Education was provided to staff regarding approved list of chemicals for facility cleaning purposes. This education included proper storage, knowledge of Safety Data Sheet (SDS) for each chemical, locking closets when not being actively used by approved staff. Rounds are being completed daily (M-F) and on weekends by medication technician to ensure staff compliance with education and security of cleaning supplies and hazardous materials. Date of correction: 6/29/23-staff education Date of correction: 7/14/2023-for family letter