VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lillian's Loving Care
3736 Turnpike Road
Portsmouth, VA 23701
(757) 393-9241

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: April 9, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

This was an unannounced complaint inspection conducted by the Licensing Inspector from the Eastern Regional Office. The inspection was conducted on April 9, 2019 from 12:05 PM until 2:42 PM. There were 28 residents in care. The complaint alleged concerns regarding the ceiling leaking, meals and menus, sanitation of bathrooms, equipment not functioning, bed and linens, as well as concerns regarding a resident's blood sugar levels. During the inspection, a tour of the physical plant was conducted. The lunch meal was observed to include baked chicken, mashed potatoes, peas, and beans. Menus were reviewed as well as the facility's current food supply. Resident records were reviewed and resident interviews were conducted. During the inspection there was discussion regarding ongoing repairs for water leak. Also discussed second servings for residents during meals, and storage of used or soiled linen. The facility received violations in the areas of Admission, Retention and Discharge of Residents, Resident Care and Related Services, and Buildings and Grounds. The information gathered during this inspection supports the allegations regarding bathrooms in the complaint, therefore the complaint was found to be valid. Please complete the "plan of correction" and "date to be corrected" for each violation on the violation notice. The plan of correction must indicate how the violation will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction should include 1. Step(s) to correct the noncompliance 2. Methods to prevent reoccurrence 3. Person(s) responsible for implementing and/or monitoring any preventative actions. If you have any questions please contact your inspector, Reyna Rios at (757) 353-0430.

Violations:

Standard #:	22VAC40-73-320-A
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure the physical examination report contain recommendations to include therapy, and include the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form completed within 30 days prior to admission. Evidence: 1. During review of resident #3's admission physical report the recommendation for therapy was left blank. During further review, Licensing Inspector found the TB screening was completed on 02-21-2019 and read on 02-24-2019, more than 30 days prior to the resident's admission on 04-01-2019. 2. During interview, staff #2 acknowledged the missing information and the TB screening date for resident #3.
Plan of Correction:	The facility will ensure to check physical examination report thoroughly and make sure that the doctor fill out the therapy section. The facility will make sure that new admissions will have Tuberculosis (TB) done 30 days prior to admission.
Standard #:	22VAC40-73-320-B
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure that a risk assessment for tuberculosis (TB) was completed annually on each resident. Evidence: 1. During review of resident records, resident #4 did not have a current TB screening. The last TB screening in the record was dated 03-26-2018. 2. During interview, staff #2 acknowledged resident #4 did not have a current TB screening.
Plan of Correction:	The facility will ensure that risk assessment for Tuberculosis (TB) will be done annually on each resident.
Standard #:	22VAC40-73-350-B
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ascertain prior to admission, whether a potential resident is a registered sex offender. The documentation of the date the information was obtained should be filed in the resident's record. Evidence: 1. During review of resident records, it was found that the facility did not have the sex offender screening prior to admission for three (3) residents admitted on 04-01-2019. Resident #1's sex offender screening was completed on 04-03-2019. Resident #2 and resident #3's sex offender screening was completed on 04-09-2019. 2. During interview, staff #2 acknowledged the sex offender screenings were completed after resident #1, resident #2, and resident #3's admission.
Plan of Correction:	The facility will make sure to obtain a sex offender record prior to admitting a resident.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure the comprehensive Individualized Service Plan (ISP) include the date needs were identified. Evidence: 1. During review of resident records, resident # 1's ISP dated 04-03-2019, the "date needs identified" was left blank for all 12 needs. 2. Resident #2's ISP dated 04-03-2019 did not include a date needs were identified for all 8 needs. 3. Resident #3's ISP dated 04-03-2019 did not include a date needs were identified for all 11 needs. 4. During interview, staff #2 acknowledged the missing dates on resident #1, #2, and #3's ISPs.
Plan of Correction:	The facility will ensure to include the date when needs identified in the residents Individualized Service Plan (ISP).
Standard #:	22VAC40-73-870-A
Complaint related:	Yes
Description:	Based on observation and interview, the facility failed to ensure the interior of the building was maintained in good repair and kept clean. Evidence: 1. During a tour of the building with staff #1, Licensing Inspectors observed in room #11 and in the gentlemen's bathroom, the sleeves on the window blinds were broken and missing. 2. In room #3 the closet door was loose with loose screws separated from the top hinge. 3. In the gentleman's bathroom, a section of the side of the wall was missing next to the step in shower. The white floor entering the shower was discolored and brown, with black spots on the right bottom corner of the front of the shower wall. The floor surrounding the toilet was also discolored with a brown rim. The linoleum floor behind the toilet was cut and separated from the floor. 4. During interview, staff #1 acknowledged the areas mentioned.
Plan of Correction:	The facility will make sure that the interior of the building will be in good repair and kept clean. The facility will ensure that all violation that was mentioned will be fix and repair.