VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Town Creek Assisted Living Facility
393 Front Street
Lovingston, VA 22949
(434) 263-4313

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: June 25, 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 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. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 SANCTIONS.

Comments:

The LI for Town Creek Assisted Living conducted an unannounced renewal study at the facility on 6/25/19 from 9:30am until 2pm under the supervision of the LA and noted 26 residents to be in care. Resident and staff records as well as other forms of facility documentation were reviewed and interviews were conducted with residents and staff. A tour of the facility physical plant was conducted and the mid day meal and medication pass were observed. Please respond beck to your LI with a plan of correction within 10 days of receipt of this notice. If you have any questions please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-270-1
Description:	Based on a review of staff records, the facility failed to ensure that direct care staff received required training prior to being involved in the care of residents who have a history of aggressive behavior or dangerously agitated states. EVIDENCE: 1. The facility does have residents who have a history of aggressive behaviors. Staff 2, hired on 05/17/2019, and staff 3, hired on 05/13/2019, have not had aggressive training.
Plan of Correction:	On 6/27/29, Administrator notified Human Resources and Training departments that no employees would be able to start work at facility prior to receiving CPI (aggressive resident training). All future new hires will be scheduled for CPI prior to first day on shift.
Standard #:	22VAC40-73-380-A
Description:	Based on a review of resident records, the facility failed to ensure that all required personal and social data was obtained prior to or at the time of admission. EVIDENCE: 1. The records for residents 1, 2, 3, and 6 did not include thorough current behavioral functioning information, to include strengths.
Plan of Correction:	On 6/27/19 and 6/28/19, Administrator and Admissions staff reviewed all resident charts and ensured all fields were properly completed on the Personal/Social Data Form. Administrator provided retraining on proper completion of all fields on this form.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that a comprehensive individualized service plan (ISP) was included all required components. EVIDENCE: 1. The ISP for resident 6, dated 04/17/2019, identifies the resident is a registered sex offender; however, the ISP failed to include a written description of the identified need, the services provided to address that need, who provides the service, when and where the services will be provided, and the expected outcome and time frame for the expected outcome.
Plan of Correction:	On 6/27/19 and 6/28/19, Administrator and Admissions staff reviewed all charts of registered sex offenders and met with Admissions staff to ensure that appropriate services and interventions were documented to ensure resident safety.
Standard #:	22VAC40-73-640-A
Description:	Based on observations, the facility failed to implement their medication management plan. EVIDENCE: 1. Opened Novolog and Humulin Insulin were noted in the medication refrigerator for resident 9. The insulin did not contain the date they were opened to ensure they are disposed of per manufacturers instructions. 2. Opened Novolog, Humalog and Levemir Insulin were noted in the medication refrigerator for resident 4. The insulin did not contain the date they were opened to ensure they are disposed of per manufacturers instructions. 3. The June 2019 medication administration records (MARs) for resident 5 has documentation that the resident has refused 24 days out of 25 to take the medications Breo Ellipta and Spiriva inhalers daily as prescribed by their physician. There is no documentation that the the person licensed/registered to administer medications who is responsible for routinely communicating issues or observations related to medication administration has notified resident 5's prescribing physician of the residents refusal to take these medications. 4. The June 2019 MAR for resident 6 has daily documentation of the resident refusing to take the prescribed medications Escitalopram 10mg, and Fluticasone Prop Nasal spray. There is no documentation that the the person licensed/registered to administer medications who is responsible for routinely communicating issues or observations related to medication administration has notified resident 6's prescribing physician of the residents refusal to take these medications.
Plan of Correction:	On 6/27/19, Administrator, Program Manager and Clinical Coordinator met with all Medication Aides to provide in-service for retraining on the facility?s Medication Management Plan with specific attention to areas cited. Administrator created Physician?s Notification Form to address any ongoing issues with resident medication refusal.
Standard #:	22VAC40-73-680-B
Description:	Based on observations made of the 11:00am medication pass, the facility failed to ensure that medications were removed from the pharmacy container and administered by the same staff person. EVIDENCE: 1. The LI observed that staff person 1 removed a Budesonide nebulizer plastic ampule from the pharmacy packaging for resident 4 and handed the medication to the resident. The resident then placed the ampule in their purse and left the medication room. The medication was signed off on the MAR as administered but staff person 1 did not administer or observe that resident 4 took the medication as ordered. The uniform assessment instrument (UAI) dated 4/15/19 has documentation that the facility administers medications and the history and physical dated 5/21/19 in the record for resident 4 has documentation that the resident is unable to self administer medications.
Plan of Correction:	On 6/27/19, Administrator, Program Manager and Clinical Coordinator met with all Medication Aides to provide re-training on 680B. Administrator is in final stage of hiring process for hiring licensed health care professional to provide increased oversight and training of medication aides and medication administration process for facility.
Standard #:	22VAC40-73-680-D
Description:	Based on observations and resident record review, the facility failed to administer medications in accordance with physician instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. The LI observed staff person 1 administer a Humalog insulin injection to resident 7 at 11:20am on the day of inspection. The LI observed that staff person 1 did not use an alcohol swab/pad to clean the injection site prior to administration. Page 278 of The Commonwealth of Virginia Board of Nursing Medication Aide Curriculum for Registered Medication Aides has listed under General guidelines for administration of subcutaneous injections (B- #7)to cleanse the injection site with an alcohol swab before administration of the injection. 2. The facility medication cart contained a full bottle of Fluticasone Propronate nasal spray for resident 10 that was delivered from the pharmacy on 2/18/19. The physician order is to administer 1 spray in each nostril at bedtime. Staff initials are present for administering this medication for a total of 111 days from 2/18/19 through 6/25/19. The medication is in a 120 metered dose bottle which with 2 spray each day at bedtime, would only last for 60 days. The LI determined that no other Fluticasone Propronate nasal spray had been delivered from the pharmacy since 2/18/19.
Plan of Correction:	Administrator, Program Manager and Clinical Coordinator met with all Medication Aides on 6/27/19 to provide in-service for retraining on the facility?s Medication Management Plan including that physician?s orders must be verified with MARs and medications administered accordingly. Observed staff involved in repeat violation for 680D no longer has medication administration responsibilities. All Bulk and OTC meds will be labeled and dated when opened to ensure compliance.