VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Elizabeth House Assisted Living
3590 Mountain Road
Glen allen, VA 23060
(804) 672-7580

Current Inspector: Belinda Dyson (804) 662-9780

Inspection Date: June 26, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 BUILDING AND GROUNDS

Technical Assistance:

1) Technical assistance and Home Office consultation as it relates to standard 22 VAC 40-73-310 as it relates to the facility's Admission and retention of residents.

Comments:

An unannounced renewal inspection was conducted on June 26, 2019, from 11:00 a.m. to 4:37 p.m. For Elizabeth House Assisted Living Facility. Upon arrival, the licensing representative met with the administrator in order to initiate the entrance conference. The facility reported the census as twenty four residents in care. After the entrance conference the assigned inspector observed a medication pass and completed a record review. The licensing representative interviewed staff, residents, and family members during the renewal inspection. The record review encompassed six (6) resident records and three employee records. After the record review the administrator and the licensing representative toured the building. All prior cited violation were corrected per the facility's plan of correction. New violations were cited during this renewal study. Please submit a written plan of correction within the next ten calendar days. Your plan should specify how you will correct each violation, how you intend to implement the future plan, provide a date of correction for each violation, and identify the individual responsible for implementing and monitoring each preventive measure. You may contact me at (804) 662-9432 or e-mail at Vashti.Colson@dss.virginia.gov to discuss any questions you may have. Thank you for your cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-310-B
Description:	VIOLATION: Based upon the record review and interviews, the facility failed to ensure that prior to each resident's admission, the facility will make a determination that the facility can meet the residents needs by obtaining a completed UAI, physical examination report, a documented interview , and a mental health screening. EVIDENCE: According to the facility?s records, resident XYZ was admitted to the facility on February 02, 2018. The resident?s UAI was dated 08/2/2018, and the physical examination was documented as 09/05/2018. Both the U.A.I. and physical examination documents that the resident has no prohibited condition prior to the resident?s admission date, 2/02/2019. Further assessment of the UAI, notes that the assessor failed to mark or indicate if resident XYZ is residential level or assisted living level of care. Instead of indicating the resident?s level of care the assessor transcribed in the level of care section of the UAI the following statement, ?Needs Nursing Continuous Care". The admission Uniform Assessment Instrument for resident XYZ identifies dependencies in all categories of bathing, dressing, toileting, transferring, eating/feeding, bowel/bladder, walking , wheeling, stair climbing, mobility, meal preparation, housekeeping , laundry and money management. The UAI and the assessment of serious cognitive impairment form documents that the resident is disoriented on all spheres all of the time. According to the telephone interviews with contacts and other medical supportive agencies, resident XYZ was admitted to the assisted living facility with at least a stage three or four decubitus ulcers. Based upon the cumulative documentation resident XYZ was admitted to the facility without a completed UAI and a physical examination which are key components in determining if the facility can provide the resident?s required level of care and needs. This is on-going.
Plan of Correction:	Elizabeth House will ensure that prior to each admission that the facility will be able to meet the resident's needs according to the physician's orders and supporting documentation. The administrator will review all required documentation before all future admissions.
Standard #:	22VAC40-73-320-A
Description:	VIOLATION: Based upon the record review, the facility failed to obtain a physical examination by an independent physician within thirty (30) days preceding the resident's admission. EVIDENCE: Resident XYZ was admitted to the facility on 2/2/2018, but the facility did not obtain a physical examination for resident XYZ until 09/5/2018. The facility failed to provide evidence during the exit conference that would dispute the cited violation.
Plan of Correction:	Elizabeth House will make sure physical examinations stay up to date every three months and in resident's charts . The clinical director will keep a calendar book to make sure all residents stay up to date with physical examinations that will be checked and monitored monthly.
Standard #:	22VAC40-73-870-A
Description:	VIOLATION: Based upon the building tour, the facility failed to maintain the exterior of the building in good repair. EVIDENCE: During the building tour, the licensing inspector noticed that the exterior patio and garden area was over grown with weeds and dead flowers. Certain areas of the patio?s fence was weathered and tattered.
Plan of Correction:	The landscaping company will take care of over grown weeds and flowers. They have already taken care of the weeds, waiting for them to come back to complete flowers beds. Should be completed by 8/09/ 2019 and we will continue to make sure the grounds stay in good upkeep. Patio fence was repaired by maintenance no 6/28/2019. Maintenance will continue to do routine maintenance as needed.
Standard #:	22VAC40-73-870-B
Description:	VIOLATION: Based upon the building tour, the facility failed to keep the building odor free. EVIDENCE: During the building tour, the licensing inspector and the facility's administrator noticed that room# 214 had a strong urine odor.
Plan of Correction:	Housekeeping cleaned the carpet on 7/1/2019. Housekeeping will make sure carpets are clean and odor free at all times. The hallways will be cleaned twice a month and rooms will be cleaned as needed and routinely every 6 months. This will be on going.
Standard #:	22VAC40-73-890-B
Description:	VIOLATION: Based upon the building tour, the facility failed to adequately light certain parts of the interior building adequately. EVIDENCE: During the renewal inspection, the licensing representative was placed in the facility's activities room to review records and conduct interviews. Upon entering the activities room, the licensing representative noticed that three out of five ceiling lights failed to illuminate or work.
Plan of Correction:	Maintenance replaced the lights in the activities room on 06/28/2019. Elizabeth House will ensure that all lights in the facility work at all times and maintenance will replace bulbs as needed on going.