VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Pearl at Watkins Centre
650 Watkins Centre Parkway
Midlothian, VA 23112
(804) 893-0067

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: May 2, 2019

Complaint Related: Yes

Areas Reviewed:

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 BUILDING AND GROUNDS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced inspection was conducted at the facility by three licensing representatives on 5/2/2019 to investigate two complaints. The complaint allegations regarding diet, medication administration, individualized service plans and hazardous materials were determined to be valid. During the complaint investigation, there were other non-compliancies found that were unrelated to the complaint. See violation notice for non-compliancies. The facility has 10 calendar days from receipt of the inspection reports to complete a plan of correction, sign the inspection reports and return them to the licensing office. A copy of the inspection reports shall be retained to be posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the VDSS website within 15 calendar, regardless of whether the plan of correction is completed .Just writing the word ?corrected? is not acceptable. The plan of correction shall include the following: (1) Step(s) the facility will take to correct the violations cited; (2) Measures that will be put in place to prevent reoccurrence of each violation; (3) Person(s) responsible for implementation and monitoring of preventive measures; and (4) Date by which each violation will be corrected.

Violations:

Standard #:	22VAC40-73-1180-C
Complaint related:	No
Description:	Based on an inspection of the facility and resident observations on 5/2/2019, the facility lacks special environmental enhancements that would enable the residents to maximize their independence and promote their dignity. Evidence: One resident (# 2) was unable to locate and/or recognize her personal space. All rooms entry doors are identical with only a room number as an identifier.
Plan of Correction:	ED or designee will communicate with families and request recommendations on what identifying item their love one would easily recognize if hung on their door. If no input is provided, the community will hang photos of the resident on the door, once it is confirmed, we have a signed consent to photograph for al purposes other than identification.
Standard #:	22VAC40-73-220-A
Complaint related:	No
Description:	Based on an inspection at the facility and interviews with staff, the facility failed (1) to obtain in writing, information on the type and frequency of the services to be delivered to the resident by private duty personnel, (2) to reflect the services provided by private duty personnel on the resident's individualized service plan, and (3) to provide orientation and training regarding the facilities policies and procedures to private duty personnel. Evidence: 1. Licensing staff observed an individual identified by staff # 1 and # 2 as a private duty person providing care to resident # 1. The facility staff did not provide at the time of the inspection any documentation on the private duty personnel including: (1) documentation of facility training or orientation for the private duty person, (2) a tuberculosis screening, or (3) information on the type and frequency of the services to be delivered to the resident by the private duty person. 2. The private duty services provided to the resident were not reflected on the services plan for resident # 1.
Plan of Correction:	ED or designee to ensure all required documentation and training is on file for private duty sitters and updated as required. The ED or designee will ensure all services being rendered by private duty personnel is included on the resident's service plan. Ed, RDO and Regional Director of Nursing will conduct random audits of the resident charts to ensure service plans are completed per state regulations and reflect recent changes in condition in addition to including services being provided by private duty personnel. All private duty personnel files will be audited at this time.
Standard #:	22VAC40-73-290-A
Complaint related:	No
Description:	Based on an inspection of the facility on 5/2/2019, the facility did not have a written work schedule that included the names and job classifications of all staff working. Evidence: Upon review, the May 2019 work schedule did not include any job classifications for any staff member.
Plan of Correction:	This was and is posted in the break with all required information.
Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on a review of resident files, a written fall risk assessment/rating was not completed for two residents after documented falls. Evidence: 1. Resident # 4 had documented falls on 3/1/2019, 4/12/2019 and 4/17/2019, a written fall risk assessment/rating was not found in the resident's file. 2. Resident # 5 had a documented fall on 4/21/2019, a writen risk assessment/rating was not found in the resident's file.
Plan of Correction:	Ed or designee to ensure initial and subsequent fall assessments are done. The Ed, RDO and Regional Director of Nursing will conduct random chart audits to ensure the fall risk assessments/ratings are being completed.
Standard #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	Based on a review of resident files, two residents did not have a documented comprehensive a comprehensive service plan completed within 30 days of admission. Evidence: 1. A review of the file for resident # 3 found a preliminary service plan dated 2/4/2019, a comprehensive service plan completed within 30 days of admission was not in the file. 2. A review of the file for resident # 4 found a preliminary service plan dated 12/27/2018 and a comprehensive service plan dated 4/2/2019, the comprehensive service plan was not completed within 30 days of admission.
Plan of Correction:	ED or designee will complete comprehensive service plan for resident # 1. All resident files will be audited to ensure each resident has a comprehensive plan. To ensure all residents receive a 30 day comprehensive plan, the ED and/or designee will utilize a tickler system to ensure all service plans are complete by due date. Ed,RDO and Regional Director of Nursing will conduct random audits of the resident charts to ensure service plans are completed per state regulations.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on a review of five (5) resident files and observations on 5/2/2019, individualized service plans were not updated as the condition of the resident changed. Evidence: 1. Resident # 5 has a diagnosis of venous insufficiency and a physician's order dated 3/1/2019 for compression stockings and leg elevation while at rest. The individualized service plan for resident # 5 dated 12/27/2018 was not updated to reflect the changes in condition and the physician's order. 2. Resident # 4 has a physician's order dated 3/20/2019 for "no concentrated sweets". The current individualized service plan that was updated 4/2/2019 does not address the identified need of no concentrated sweets. 3. Resident # 4 has a documented diagnosis of urinary tract infection (UTI). The individualized service plan for this resident was not updated to address the condition.
Plan of Correction:	ED or designee will review and update ISPs to document resident change in conditions. Ed, RDO and Regional Director of Nursing will conduct random audits of the resident charts to ensure service plans are completed per state regulations and reflect changes in condition.
Standard #:	22VAC40-73-460-I
Complaint related:	No
Description:	Based on an inspection at the facility on 5/2/2019, the facility did not ensure that one resident was free of odors related to hygiene. Evidence: During an interaction between resident # 2 and a licensing staff, resident was found with a foul mouth odor.
Plan of Correction:	Ed or designee to update ISP as to family communicating, continue to have problems with halitosis related to GI problems.
Standard #:	22VAC40-73-530-C
Complaint related:	No
Description:	Based on an inspection of the facility on 5/2/2019, the facility failed to provide freedom of movement to residents' own personal spaces. Evidence: 1. An inspection of the facility on 5/2/2019 found the rooms of residents # 8, # 2, # 9 , # 10 locked from the outside, not allowing access to the residents. 2. A licensing representative asked resident # 2, who had a key fob to operate the door to her room on her wrist, to open her door. Once a staff member showed her the location of her room, the resident began pulling on the door handle and stated "I don't know how to work it".
Plan of Correction:	ED submitted an allowable variance for the identified residents as families have requested doors remain locked.
Standard #:	22VAC40-73-610-D
Complaint related:	Yes
Description:	Based on a review of the file for one resident and an interview with the resident's responsible party, a diet prescribed for the resident is not being prepared and served according to the prescriber's order. Evidence: A physician's order dated 3/20/2019 for "no concentrated sweets" was found during a review of the file for resident # 4 on 5/2/2019. The facility's diet book did not document the order, the diet book documented that the resident is on a regular diet. Staff interviewed was not aware that the resident's diet change.
Plan of Correction:	ED or designee to give all changes in diet orders to FSD who is to post on diet board to ensure all diets are followed, as prescribed, and educate staff of the changes. Ed,RDO and Regional Director of Nursing will conduct random audits of the resident charts to ensure service plans are completed per state regulations and reflect recent changes in condition including diet changes.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on a review of the medication administration record (MAR) for one resident, medications that were not administered were documented as administered on the MAR. Evidence: Divalproex, Cephalexin, ad Metamucil powder was documented as administered on 4/20/2019. Resident was admitted to the hospital on 4/18/2019 and transferred directly to a rehabilitative facility upon hospital discharge.
Plan of Correction:	ED or designee to put residents out of facility on EMAR when resident out. Also educate staff to ensure if resident out and still on EMAR to put resident out of facility.
Standard #:	22VAC40-73-860-J
Complaint related:	Yes
Description:	Based on an inspection of the facility on 5/2/2019, hazardous materials were accessible to the residents in care. Evidence: The facility is a safe, secure facility, all residents have a serious cognitive impairment. Several aerosol cans were found in an open closet in the room of resident # 3. The closet door and the door to the residents room were open and the items were accessible to other residents in care. (picture taken)
Plan of Correction:	FD or designee will do room sweeps regularly to verify all closet doors are locked and any materials of potential question be locked in the locked closet. Ed, RDO and Regional Director of Nursing will conduct random environmental rounds when onsite to ensure there are no hazardous materials accessible to residents.
Standard #:	22VAC40-73-930-D
Complaint related:	No
Description:	Based on a review of individualized service plans, the service plans did not include the residents' inability to use the signaling device (call bell) in place and frequently of rounds. Evidence: The facility is a secure memory care facility for individuals with a serious cognitive impairment. Observations of the residents in care found that several residents were unable to use the call bells located in their attached bathrooms when prompted by licensing staff. Facility staff reported that the residents have pendants, but "cannot use them".
Plan of Correction:	ED or designee to update all ISPs to communicate the inability of residents to use signaling device and provide frequency of rounds. Ed,RDO and Regional Director of Nursing will conduct random audits of the resident charts to ensure service plans are completed per state regulations and reflect recent changes in condition including the resident's ability to use the signaling device (call bell).