VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Fort Shelby Manor
200 Solar Street
Bristol, VA 24201
(276) 669-3562

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: May 20, 2019

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE.

Comments:

Two licensing inspectors conducted a one day unannounced mandated monitroing inspection at Forth Shelby Manor on 05/22/2019. The inspection started at 10:30 am and concluded at 3:08 pm. During the inspection the noon med pass was observed, buildings observed, residents observed, resident and staff interaction observed, a sample of resident and staff records were reviewed, resident and staff interviews were conducted, and lunch was observed. The facility had 36 residents in care the day of inspection. An exit meeting was held with the administrator of the facility on 05/22/2019 and at that time an opportunity was given to find items not available in files and violations were reviewed. As a result of this inspection there are 11 violations being cited. Please develop a "plan of correction" and "dated to be corrected" for each violation cited and return to the licensing office within 10 calendar days (06/02/2019) of receipt. If you have any questions or concerns please contact your inspector at 276-608-3514. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-100-A
Description:	Based on observations made during the medication cart audit, the facility failed to implement their infection control program designed to prevent and control disease and infection that is consistent with the federal Centers for Disease Control and Prevention (CDC) guidelines. EVIDENCE: 1. The blood glucose monitoring supplies for resident #1 were not labeled properly. The bag containing the blood glucose monitor was labeled on the outside but the individual monitor was not labeled with resident # 1's name.
Plan of Correction:	The glucose monitor for Resident # 1 is now labeled with her name. All glucose moniters will by labeled with the Residents name in the future. The Administrator will ensure that this is done. [sic]
Standard #:	22VAC40-73-290-B
Description:	Based on observations made during the tour of the building, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a place in the facility that is conspicuous to residents and visitors. EVIDENCE: 1. During the tour of both houses, the licensing inspector was not able to locate a posting of the current on-site person in charge.
Plan of Correction:	The current on-site person us currently posted as of this date and the Administrator will see that this is done in the future. [sic]
Standard #:	22VAC40-73-320-A
Description:	Based on review of resident records, the facility failed to ensure the physical exam for residents contained all of the required information. EVIDENCE: 1. Resident # 1 had a physical exam dated 02/26/2019. The physical exam listed resident #1 is allergic to Penicillin and Sulfa Drugs and there were no reactions to these medications listed. The statement regarding resident# 1's capability of self-administering medications was not listed. 2. Resident # 6 had a physical exam dated 02/13/2019. The physical exam did not include the statement regarding resident # 6's ablity to self administer medications.
Plan of Correction:	Resident # 1 says Penicillin and Sulfa causes rash (now documented on physical form and ISP). The Administrator will see that future physical exams having allergies listed will also have reactions, if known. Resident # 1's capability of self administration medications and also Resident # 6 has been listed by Teresa Pennington N.P. Also this will be addressed on future physical exam forms. [sic]
Standard #:	22VAC40-73-380-A
Description:	Based on review of resident records, the facility failed to ensure the personal and social information for residents contained all of the required information. EVIDENCE: 1. The personal and social data sheet for resident # 1 did not include information for the lifetime vocation, career, or primary role of this resident.
Plan of Correction:	The administrator will ensure that all information is gotten on the personal and social data sheet of Resident # 1 and in the future of all new Residents. [sic]
Standard #:	22VAC40-73-450-C
Description:	Based on review of resident records and Individual Service Plans (ISP), the facility failed to ensure the comprehensive service plan included all of the identified needs on the resident's Uniform Assessment Instrument (UAI). EVIDENCE: 1. Resident # 1 had a UAI dated 02/26/2019 that addressed a need for mechanical help with transferring. The need for help with transferring was not addressed on the ISP for resident # 1. 2. The UAI for resident # 1 dated 02/26/2019 stated stair climbing for this resident was not applicable. Staff # 2 stated this resident does climb stairs in the front of the building and requires a handrail for stair climbing. This need was not addressed on the ISP dated 02/26/2019 for resident # 1. 3. Resident # 1 had an UAI dated 02/26/2019 that addressed a need for mechanical help with mobility. The need for help with mobility was not addressed on the ISP for resident # 1.
Plan of Correction:	The Administrator will ensure that all the Residents needs are addressed on the UAI and the ISP or Resident # 1 and on all residents in the future. [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on observations made during the medication cart audit, interviews with staff and documentation review, the facility failed to follow their medication management plan by not keeping an accurate count of all controlled substances at the change of each staffing shift. EVIDENCE: 1. Staff # 4 stated the facility keeps a count of controlled substances that are on an as needed basis. The controlled scheduled medications are packaged with other scheduled medications and those controlled substances are not counted.
Plan of Correction:	The Administrator will ensure that all controlled substances will be counted and documented at each shift change according to the medication management plan. The controlled scheduled medications will be packaged separately as if this date. [sic]
Standard #:	22VAC40-73-650-E
Description:	Based on observations made during review of the resident records, the facility failed to have all physician orders organized chronologically in the resident?s record. EVIDENCE: 1. Resident # 12 was discharged from the hospital on approximately 04/16/2019 with new medication orders which included Senexon-S two tablets daily as needed. 2. Staff # 5 stated she knew Resident # 12?s Senexon-S two tablets daily as needed had been discontinued since the new medications orders were received when licensing inspector was comparing medications to physician?s orders to the Medication Administration Record (MAR). 3. The Senexon-S was not on the medication cart in the White House, and it was not on the current MAR. 4. Licensing Inspector could not locate the discontinue order in Resident #12?s file, but Staff # 6 did have the pharmacy to fax the discontinue order to the facility while the licensing inspector was present.
Plan of Correction:	The Administrator will ensure that all doctors orders are in the Resident's file and on the floor and that all medications match up to the current doctors orders. [sic]
Standard #:	22VAC40-73-680-D
Description:	Based on review of Medication Administration Records (MAR), physician's orders for residents and staff interviews, the facility failed to ensure medications are administered in accordance with physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing for one resident in a sample of four. EVIDENCE: 1. Resident # 11 is prescribed Amitiza 24 MCG capsules. The physicians order states for resident # 11 to take one capsule by mouth twice daily with breakfast and dinner. According to the MAR and staff # 2 this resident receives her second dose of this medication at 4 pm. Staff # 2 stated dinner is served between 4:30pm and 5:00pm. Therefore, resident # 11 is getting her second dose of medication before dinner instead of with dinner as prescribed.
Plan of Correction:	The Administrator will ensure that the Pharmacy packages medications according to the doctors orders and that they are administered according to doctors orders. Resident # 11's Amitiza has been packaged t o give at 5:00 pm with the evening meal. [sic]
Standard #:	22VAC40-73-680-M
Description:	Based on review of Medication Administration Records (MAR) and resident records, the facility failed to ensure medications ordered on an as needed basis (PRN) administration were available for one resident in a sample of eight. EVIDENCE: 1. Resident # 9 is prescribed Lorezepam 0.5 mg to be given 1 tablet every eight hours as needed for anxiety. The last tablet was given on 05/09/2019. Staff # 6 stated this resident has an upcoming appointment to see her physician for a new order for this medication which is not until May 28, 2019. This medication was not available for administration for resident # 9.
Plan of Correction:	The Administrator will see that all Residents have their medications available as ordered. When the medication is a controlled substance the doctor will be called for an appointment in order for the medication to be available. [sic]
Standard #:	22VAC40-73-860-G
Description:	Based on observations made during the tour of the building, the facility failed to ensure water temperatures are within the required range of 105-120 Degrees Fahrenheit. EVIDENCE: 1. During the tour of the White House, the water temperature in the sink in resident room #5 was measured at 122.2 Degrees Fahrenheit.
Plan of Correction:	The Administrator will ensure that the water temperature does not exceed 105-120 degrees in both houses. This will be monitored at least two times weekly to make sure the water is within the proper temperature. [sic]
Standard #:	22VAC40-73-860-I
Description:	Based on the morning tour of the building, the facility failed to store cleaning supplies and other hazardous materials in a locked area. EVIDENCE: 1. The Licensing Inspector observed a bottle of Greased Lighting Cleaner sitting on a top shelf in the common bathroom on the second floor next to the elevator in the brick house. The bottle of cleaner was within reach of residents and was labeled keep out of reach of children product may be harmful.
Plan of Correction:	The Administrator will ensure that all cleaning supplies are kept out of reach of the Residents. Housekeeping will be monitored daily and reminded to keep cleaning supplies with them at all times. [sic]