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Golden Years Assisted Living Facility, Inc.
40 Hunt Club Boulevard
Hampton, VA 23666
(757) 825-2425

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: March 20, 2019 and April 1, 2019

Complaint Related: Yes

Areas Reviewed:
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
22VAC40-73 PERSONNEL
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
22VAC40-73 BUILDING AND GROUNDS

Comments:
An unannounced two day complaint inspection was conducted by two Licensing Inspectors from the Eastern Regional Office on 03-20-2019 from 12:15 PM to 4:29 PM and by the Licensing Inspector and APS on 04-01-2019 from 10:56 AM to 5:03 PM. The complaint was regarding resident care and related services. There were 68 residents in care at the time of the inspection. A tour of the facility was conducted. During the tour, LI was unable to access to room #32 due to the room being locked and room #54 was being used as storage according to staff. 8 resident records and 3 staff records were reviewed and interviews were conducted with residents and staff. The following was discussed with the Administrator throughout the inspection: incident reports, Admission and Retention of residents, and staff supervision. The complaint was found to be not valid at this time, however, noncompliance was discovered in other areas. The facility received violations "under" Administration and Administrative Services, Personnel, Admission, Retention, and Discharge of Residents, Resident Care and Related Services, and Buildings and Grounds. The areas of noncompliance were discussed with the Administrator throughout the inspection and during the exit interview. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the Violation Notice and return it to me within 10 calendar days from today on 05-26-2019. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1. Steps to correct the noncompliance 2. Measures to prevent reoccurrences; and 3. Person (s) responsible for implementing and monitoring each step of the corrective measures and /or monitoring any preventive measure(s).

Violations:
Standard #: 22VAC40-73-70-A
Complaint related: No
Description: Based on record review and interview, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. On 04-01-2019, during resident record review, the Licensing Inspector (LI) observed the following: a. The ?Administrator Notes? dated 03-26-2019 stated ?resident #7 c/o resident #5 touching her breasts and put his hand down the back of her pants.? b. The ?Nurse?s Notes? dated 12-23-2019 stated ?? The paramedics stated they received a call from resident #6 that she slit her wrist. The paramedics followed me to her room. Resident #6 pretended that she was sleeping. The resident opened her eyes and stated that she slit her wrist? HPD and Paramedics decided to take her to the hospital to have CSB evaluate her.? c. The hospital notes dated 02-19-2019 revealed resident #4 was admitted from the facility to the hospital due to overdose. d. The shift communication log dated 04-01-2019 which stated ?resident #8 was spotted outside the facility by a gentleman that lives in the neighborhood. The person he was describing is resident #8. A resident and aide was redirecting her to return to the facility. Resident #8 was near the corner of Todds Lane about to cross over to Aberdeen and Mercury. I call HPD (police) and the officer came.? e. LI did not receive documentation within 24 hours from the facility regarding the aforementioned incidents. 2. During interview on 04-01-2019, staff #2 acknowledged the facility did not report the aforementioned incidents to the regional licensing office within 24 hours of the incident occurring.

Plan of Correction: Going forth all incidents that happens will be reported to licensing within 24 hours.

Standard #: 22VAC40-73-130-A
Complaint related: No
Description: Based on record review and interview the facility failed to ensure all staff who are mandated reporters under ? 63.2-1606 of the Code of Virginia reported suspected abuse of residents. Evidence 1. On 03-20-2019, during resident record review with staff #1, the facility ?Shift Communication Log? dated 03-09-2019 during the 3:00 PM to 11:00 PM shift revealed that resident #10 went down to resident #11?s room and began to physically assault the resident. Resident #11?s roommate was "unable to get resident #10 off of resident #11." The staff documented she did not see the assault as she was in the dining room but there were witnesses. The report also indicated resident #11 wanted to press charges because she could not defend herself and she was afraid of resident #10. The report indicated resident #11 told staff this was not the first time this had happen. It was documented in the report that the staff talked resident #11 out of pressing charges. The report indicated both staff #2 and staff #1 were notified of the incident . 2. During interview on 03-20-2019, staff #1 acknowledged the facility did not report the aforementioned incident to Adult Protective Services, Licensing, or Law Enforcement.

Plan of Correction: All reports of resident abuse will be reported to A.P.S & Licensing within 24 hrs. Aggressive residents will be discharged.

Standard #: 22VAC40-73-250-C
Complaint related: No
Description: Based on record review and interview, the facility failed to ensure personal and social data are maintained on staff and included in the staff record to include Verification that the staff person has received a copy of his current job description, and documentation of orientation as required by this chapter. Evidence: 1. On 04-01-2019, during staff record review with staff #2, the Licensing Inspector observed the following: a. Staff #3 (hired as a Certified Nurse Aide on 11-27-2018), staff #4 (hired as a cook on 09-18-2017), and staff #5 (hired as a cook on 01-22-2018), did not have signed job descriptions on file. b. Staff #3 did not have documentation of an orientation on file. 2. During interview on 04-01-2019, staff #2 acknowledged the aforementioned items were missing from staff #3, #4, and #5?s record.

Plan of Correction: Signed job description, orientation, & all admission paperwork will be filled out & signed before staff start to work.

Standard #: 22VAC40-73-310-H
Complaint related: No
Description: Based on record review and interview, the facility failed to ensure in accordance with ? 63.2-1805 D of the Code of Virginia, assisted living facilities did not admit individuals with any prohibitive conditions or individuals presenting an imminent physical threat or danger to self or others or individuals. Evidence: 1. During resident #7?s record review on 04-01-2019, the resident admitted to the facility on 12-07-2018. The admission UAI dated 12-05-2018 stated ?Patient is suicidal and found to be a danger to herself.? The UAI also indicated the resident ?has been feeling suicidal, and her plan is to cut herself with a knife.? 2. During resident #1?s record review on 03-20-2019, the resident admitted to the facility on 11-01-2018. The physical examination dated 10-18-2018 did not include a statement that the individual does not have any prohibitive conditions. 3. During interview on 03-20-2019, staff #1 and staff #2 confirmed resident #1?s physical examination dated 10-18-2019 did not include a statement or list of prohibitive conditions. Staff #1 and staff #2 also acknowledged resident #7's admission UAI indicated the resident was a danger to herself.

Plan of Correction: In the future anyone with documentation stating they are suicidal or potientaly harm themselves or others will not be admitted to our facility.

Standard #: 22VAC40-73-320-A
Complaint related: No
Description: Based on record review and interview, the facility failed to ensure within the 30 days preceding admission, a person had a physical examination by an independent physician. Evidence: 1. On 03-20-2019, during resident #3?s record review with staff #1, the resident-personal social data revealed the resident admitted to the facility on 11-20-2018; however, the physical examination was dated 12-03-2018. 2. During interview on 03-20-2019, staff #1 acknowledged resident #3?s physical examination was not completed prior to the resident admitting to the facility. 3. On 04-01-2019, during resident #7?s record review with staff #2, the resident-personal social data revealed the resident admitted to the facility on 12-07-2018; however, the physical examination was dated 02-20-2019. 4. During interview on 04-01-2019, staff #2 acknowledged resident #7?s physical examination was not completed prior to the resident admitting to the facility.

Plan of Correction: There will be no resident admitted without current H&P and TB. RCC to check each chart before admission.

Standard #: 22VAC40-73-470-F
Complaint related: No
Description: Based on record review and interview, the facility failed to ensure when the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately. Evidence: 1. On 04-01-2019, during resident #4?s record review with staff #2, the ?Nurse's Notes? dated 02-16-2019 stated ?... I received a call from resident #4?s caseworker. The caseworker stated that resident #4 stated she wanted to end her life. Resident #4 stated she took a bottle of pills. Resident #4 complained she didn?t receive her morning medications. I contacted staff #2; our administer and explained the situation to her. Staff #2 arrived at our facility about 10:00 AM. I proceeded to look for resident #4?s medications? Staff #2 witness me giving her (resident #4) the medications... Previously when I went back to resident #4?s room, I told her I needed to take her vitals. Resident #4 stated ?that won?t be necessary.? Staff #2 and I spoke outside. Staff #2 according to her conversation with resident #4 is that she lied and didn?t take a bottle of pills. Resident #4 only took the medications I gave her. Staff #2 stated she explained to resident #4 it?s not exceptable to call caseworkers and causing conflict with the staff with lies and seeking unnecessary attention... Staff #2 told me to start a 24 hour suicide watch log starting from 10:30 AM on 02-16-2019. Staff #2 told resident #4 to come out of her room and come sit in the T.V. room. At 12:30 PM the aide stated she was in the activity room. The aide did her rounds and discovered that resident #4 appeared to look out of it; something wasn?t right. I called 911. I got the documents ready for the paramedics. The Aide and I went back to the room to search the room. We found a bottle of chloroseptic sore throat liquid. The liquid had a 8/2012 date...? In addition, the ?Nurse?s Notes? dated 02-11-2019 stated ?spoke with life caseworker and resident #4 stated she wants to commit suicide. A every hour check has been put in place...? 2. Upon further review of resident #4?s record, the hospital report dated 02-19-2019 stated ?EMS states resident #4 found unresponsive by nursing staff at the facility in the dayroom. She is currently only responsive to pain... RNs were told by the facility nursing staff, resident #4 apparently told someone that she took an extra dose of one of her medications this morning, but unsure which medications. She is lethargic and unable to follow commands. UDS was positive for amphetamines and benzos. Chest X-Ray is suspicious for aspiration. Resident #4 takes Elavil, Topamax, Fioricet, Ativan as prescribed by pain management for chronic neuropathic pain. Resident #4 was started on IV Zosyn in the ED. Acetaminophen level was 44? Resident #4 reported that she had an argument with the medication technician and the assisted living and became very upset and felt hopeless and reported to that she took medication ?samples? that she had, including >20 samples of Tylenol, 50 tablets of Imitrex and 50 tables of Flexeril...? In addition, the hospital report revealed resident #4 was admitted into the Intensive Care Unit due to overdose and acute toxic encephalopathy. 3. During interview on 04-01-2019, the Licensing Inspector asked staff #2 to provide documentation of the 24 hour suicide watch log that was implemented for resident #4 on 02-16-2019 and 02-11-2019. Staff #2 indicated the facility did not have documentation of the hourly checks being performed for resident #4. 4. Staff #2 acknowledged that on 02-16-2019, medical attention was not secured immediately from the time staff was notified of resident #4 taking the bottle of pills.

Plan of Correction: E.M.S is to be called immediately for any resident stating they want to end their life or has tried to do so. There will weekly rounds made to check for any medication in resident's rooms.

Standard #: 22VAC40-73-660-B
Complaint related: No
Description: Based on observation, record review, and interview, the facility failed to ensure a resident was permitted to keep their own medication in an out-of-sight place in their room if the Uniform Assessment Instrument (UAI) has indicated that the resident is capable of self-administering medication. Evidence: 1. On 03-20-2019, during the tour of the facility with staff #1, the Licensing Inspector and staff #1 observed a bottle of Lotemax eye drops located on resident #2?s night stand. 2. During resident #2?s record review on 03-20-2019, the resident?s current UAI dated 03-18-2019 indicated that medications are to be administered by a lay person. In addition, the resident did not have a physician?s order on file for the Lotemax eye drops or to self-administer medications. 3. During interview on 03-22-2019, staff #1 acknowledged resident #2 was not permitted to keep the Lotemax eye drops in her room per the UAI. 4. Additionally, during resident #4?s record review on 04-01-2019, the ?Nurse's Notes? dated 02-16-2019 revealed the staff found a bottle of ?chloroseptic sore throat liquid? in the resident?s room with a date of ?08/2012.? The current UAI dated 08-08-2018 indicated that medications are to be administered by a lay person.

Plan of Correction: Residents was informed that they can not have OTC medications in their rooms without physician's order. Staff to monitor and report to RCC or RMA in charge.

Standard #: 22VAC40-73-860-I
Complaint related: No
Description: Based on observation and interview, the facility failed to store cleaning supplies and other hazardous materials in a locked area. Evidence: 1. During the tour of the facility on 03-20-2019 with staff #1, the Licensing Inspector and staff #1 observed a cleaning cart that was stored in an unlocked room (Rm #54). The cleaning cart contained the following cleaning supplies: Clorox urine remover, lemon furniture polish, glass cleaner, Clorox disinfecting wipes, Lysol toilet bowl cleaner, and window cleaner. 2. During interview on 03-20-2019, staff #1 acknowledged the aforementioned cleaning supplies were not stored in a locked area.

Plan of Correction: Will assure that cleaning supplies are in a locked area when not being used. All housekeeping staff have been counseled.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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