VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Emily Green Shores
500 Westmoreland Avenue
Portsmouth, VA 23707
(757) 399-3442

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: May 14, 2019 and May 15, 2019

Complaint Related: No

Areas Reviewed:

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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-90 The Criminal History Record Report

Comments:

This was an unannounced renewal inspection conducted by the Licensing Inspector from the Eastern Regional Office. The inspection was conducted on May 14, 2019 from 9:04 AM until 4:40 PM and on May 15, 2019 from 12:03 PM until 4:20 PM. There were 28 residents in care. During the inspection, a tour of the building was conducted. A medication pass was observed. Resident and staff records were reviewed, to include criminal background checks for all new staff since the previous inspection. Resident and family interviews were conducted. A lunch meal was observed as posted on the menu. Several activities were also observed throughout the inspection. A review of the facility's reports and emergency preparedness supplies was also conducted. The following was discussed during the inspection: Health care oversight dates and residents reviewed, Activity calendar: end time or duration for all activities scheduled, Written responses to resident council meeting concerns. The facility received violations under Personnel, Admission, Retention and Discharge of Residents, Resident Care and Related Services, and Emergency Preparedness. The areas of non-compliance were reviewed with the Administrator on the first day of the inspection and the Administrator's designee on the second day of the inspection. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice. The violation notice 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 with the standards. 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative actions.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on record review and interview, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and prior to coming in contact with residents, submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment should be no older than 30 days. Evidence: 1. On 05-14-2019, Licensing Inspector observed staff #5 administering eye drops to a resident and providing resident care. 2. During review of staff #5's record, staff #5's date of hire was 05-03-2019. Staff #5's TB screening in the record was dated 07-16-2018. 3. During interview, staff #1 acknowledged the TB screening for staff #5 was older than 30 days and indicated the staff did not have a more current TB screening on file.
Plan of Correction:	Upon hiring, the Administrator will give the new hire the tuberculosis state model form and will monitor to ensure that the employee' TB test and/or chest x-ray is not older than 7 days prior to first time the employee is on the schedule. Administrative Assistant will continue to monitor tickler for compliance.
Standard #:	22VAC40-73-325-B
Description:	Based on record review and interview, the facility failed to ensure the fall risk rating was reviewed and updated after after each fall. Evidence: 1. During review of resident #1's record, Licensing Inspector (LI) observed the resident had a fall on the following days: on 02-27-2019 the resident was found on the floor in her room, on 03-25-2019 the resident had a fall in her room, on 03-31-2019 the resident was found on her bathroom floor, and on 05-08-2019 the resident had an unwitnessed fall in her room. LI was unable to locate a fall risk rating completed after each fall. In addition, LI could not locate the fall risk rating completed upon completion of the comprehensive Individualized Service Plan (ISP), which was dated 09-10-2018 and indicated that the resident was assessed at an Assisted Living level of care. 2. During interview, staff #1 acknowledged that a fall risk rating was not completed for resident #1 upon completion of the comprehensive ISP and a fall risk rating was not completed for the resident after each of the resident's falls on the aforementioned dates.
Plan of Correction:	Upon admission of a resident, after a resident fall and when there is a change of the resident's assisted living level, the Administrator will complete a fall risk assessment and will have the R.C.C. add the fall risk to the resident's ISP.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview, the facility failed to ensure the comprehensive Individualized Service Plan (ISP) include a description of the resident's identified needs based upon the Uniform Assessment Instrument (UAI) and the admission physical examination report. Evidence: 1. During review of resident #1's record, the admission physical examination report dated 08-29-2018, documented the following allergies for resident #1: "Hives from Erythromycin, Penicillin, Cipro and Indocin". Review of resident #1's comprehensive ISP dated 09-10-2018, revealed the ISP did not include a description of the resident's allergies and reaction to Erythromycin, Penicillin, Cipro and Indocin. 2. During review of resident #2's record, the UAI dated 10-08-2018 indicated the resident needs "human help/physical assistance" with bathing and "human help/supervision" with dressing. During review of the resident's ISP also dated 10-08-2018, the ISP did not include a description of the resident's need for physical assistance with bathing and dressing. 3. During interview, staff #2 acknowledged resident #2 is on the shower list and receives assistance with bathing from facility staff on Tuesdays and Fridays. Staff #1acknowleged the allergy information was not included on resident #1's ISP, and resident #2's need for assistance with bathing and dressing was not included on resident #2's ISP.
Plan of Correction:	The Administrator will review the physical and UAI prior to signing ISP completed by the R.C.C.
Standard #:	22VAC40-73-950-C
Description:	Based on record review and interview, the facility failed to conduct a semi-annual review on the emergency preparedness and response plan for all staff, residents and volunteers. The review should be documented by signing and dating. Evidence: 1. During review of facility records with staff #2, staff #2 provided Licensing Inspector with documentation of the most current semi-annual review on the emergency preparedness and response plan. The emergency preparedness and response plan review was conducted on 09-06-2018 with staff and on 09-11-2018 with residents. 2. Staff #2 was unable to provide documentation of a review conducted for residents, staff and volunteers after 09-2018.
Plan of Correction:	The Emergency Preparedness and Response plan will be reviewed with staff, residents, and volunteers every January and July. The Administrator will conduct the review and the Administrative Assistant will develop and implement the tickler to ensure compliance with the standard. The Administrative Assistant will also monitor the tickler and obtain signatures to insure participation and compliance.
Standard #:	22VAC40-73-970-A
Description:	Based on record review and interview, the facility failed to ensure the fire and emergency evacuation drills were conducted on each shift in a quarter. 1. During review of the fire and emergency evacuation drill report, the facility failed to conduct a drill on the 11 PM- 7 AM shift. The last drills conducted as indicated on the report were 04-28-2019 at 1:25 PM (7 AM-3 PM shift), 03-25-2019 at 7:40 AM (7 AM- 3 PM shift), 02-26-2019 at 5:30 PM (3 PM - 11 PM shift), and 01-25-2019 at 1: 50 PM (7 AM- 3PM shift). 2. During interview, staff #2 acknowledged the facility's shifts are 7 AM-3 PM, 3 PM-11 PM, and 11 PM-7 AM and that the fire and evacuation drill report did not reflect a drill was conducted on the 11 PM-7 AM shift for the past quarter.
Plan of Correction:	The Buildings and Grounds director will conduct fire drills for each shift. The Buildings and Grounds director will ensure that the 11pm-7am shift drill is performed at least one hour prior to the 7am shift.
Standard #:	22VAC40-73-980-A
Description:	Based on observation and interview, the facility failed to ensure items in the first aid kit with expiration dates must not have dates that have already expired. Evidence: 1. During review of the facility's first aid kit with staff #2, Licensing Inspector (LI) observed the expiration date for the antiseptic ointment was 8-2018, and the expiration date for the hand sanitizer was 01-2015. During a check of the first aid kit for the activity van, LI observed the expiration date on the antiseptic ointment was 02-2019. In addition, the van first aid kit was missing a blanket. 2. During interview with staff #2 and staff #3 acknowledged the antiseptic ointment and hand sanitizer in the first aid kit for the building were past their expiration date. During a separate interview, staff #4 acknowledged the expired antiseptic ointment and the missing blanket for the activity van's first aid kit.
Plan of Correction:	The Resident Care Coordinator, R.C.C. will conduct inspection of the first aid kit in the building. The R.C.C. will report to the Administrator that this has been completed on a weekly report. The Activity Director will inspect the first aid kit in the van monthly and the R.C.C. will check off on the inspection monthly.
Standard #:	22VAC40-73-990-C
Description:	Based on record review and interview, the facility failed to ensure at least every six months all staff on each shift participate in an exercise in which the procedures for resident emergencies are practiced. Evidence: 1. During review of facility records with staff #2, staff #2 provided Licensing Inspector with documentation of the last exercise for resident emergencies practiced on 07-13-2018. A review of the resident emergencies procedures was conducted with staff on 03-15-2019 and on 04-15-2019; however, staff #2 was unable to provide documentation that the procedures for resident emergencies were practiced by all staff on each shift after 07-13-2018. 2. During interview, staff #2 acknowledged that the most recent documented practice exercise for resident emergencies was on 07-13-2018, which is over 6 months.
Plan of Correction:	Comprehensive Emergency preparedness in-services with role play will be conducted and documented with all staff from all shifts every January and July. The Administrative Assistant will develop, implement, and monitor a tickler to ensure compliance.