VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Mennowood Retirement Community
13030 Warwick Blvd.
Newport news, VA 23602
(757) 249-0355

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: July 12, 2019

Complaint Related: No

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

Comments:

An unannounced monitoring inspection due to a self-reported incident was conducted by two Licensing Inspectors on July 12, 2019 from 8:59 a.m. to 12:58 p.m. There were 72 residents in care. Resident and staff records were reviewed and interviews were conducted during the inspection. The following was discussed during the inspection: Tuberculosis screenings, Resident Agreements, ensuring staff orientation is signed and dated, third parties and resident records. Please submit your ?plan of correction? and ?date to be corrected? for each violation cited and return all inspection reports signed and dated within 10 calendar days. The plan of correct must indicate how the violation will be or has been corrected. Just writing the word ?corrected? is not acceptable. The plan of correction must include: 1. Step(s) to correct the noncompliance with the standard(s) 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative measures. If you have any questions, please contact your inspector Alexandra Poulter at 757-613-5133 or by email at alexandra.poulter@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on record review, the facility failed to ensure that the Disclosure statement contained information on whether or not the facility maintains liability insurance that provides at least the minimum amount of coverage established by the board for disclosure purposes set forth in 22 VAC 40-73-45. Evidence: 1. Review of the facility?s Disclosure statement did not contain details on liability insurance held by the facility. 2. Staff #1 confirmed that the current disclosure statement as of 7-12-19 did not contain liability insurance information.
Plan of Correction:	Disclosure statement was updated to include information on whether or not the facility maintains liability insurance on 8/16/19. Administrator or designee will audit disclosure statement annually to ensure liability insurance coverage is accurate.
Standard #:	22VAC40-73-250-C
Description:	Based on record review and staff interview, the facility failed to ensure that a staff record contained all required information. Evidence: 1. Staff #5?s date of hire was 3-06-19. The record did not contain a copy of the Sworn Disclosure statement. 2. Staff #4 confirmed the Sworn Disclosure document was not in the file, stating that the record had been purged upon Staff #5?s termination on 5-25-19.
Plan of Correction:	All new hires will sign Sworn Disclosure statement. Administrator or designee will audit employee files monthly to ensure signed Sworn Disclosure statement is maintained in the file.
Standard #:	22VAC40-73-325-A
Description:	Based on record review, the facility failed to ensure that a fall risk rating was updated after a fall. Evidence: 1. Resident #2?s `Service Notes? documented resident had a fall on 1-28-19 at 8:30 p.m. The note documented: ?CNA stated after doing PM care in the bathroom, was taking resident out with walker and resident began to lean backwards then fell to the floor. Fall was witnessed, did not hit head. Resident fell on buttocks then laid on floor with head towards shower and feet towards door.? 2. Staff #2 confirmed resident #2 had a fall and that the last fall risk rating seen in the chart was 1-06-19.
Plan of Correction:	Fall risk ratings will be updated after every resident fall. Administrator or designee will audit resident files monthly to ensure fall risk ratings are up to date.
Standard #:	22VAC40-73-450-E
Description:	Based on record review and interview, the facility failed to ensure that the Individualized Service Plan (ISP) was signed and dated by the resident or his legal representative to include reviews and updates of the plan. Evidence: 1. Resident #2?s date of admission was 10-01-16. Resident?s ISP dated 6-22-18 had nine subsequent updates with the last update being by staff on 12-23-18; however, resident #2 nor their legal representative had signed the ISP since 6-22-18. 2. Resident #3?s date of admission was 7-12-18. Resident?s ISP dated 7-06-18 had four subsequent updates with the last updated being by staff on 4-17-19; however, resident #3 nor their legal representative had signed the ISP. 3. Resident #3?s record contained documentation that resident was receiving home health services for evaluation of cognitive impairment on 5-3-19, with a start of service on 5-4-19. Documentation revealed services received on 5-8, 5-10, 5-15, 529, 5-28, 5-30 and services discontinued on 5-31-19. The ISP was not updated to reflect `discontinued services ?goal met.? According to staff #2, resident?s services were discontinued and ISP not updated to reflect outcome date. 4. Staff #1, #2, and #3 confirmed that resident #2 and resident #3 had not signed the updated ISPs or updated services on the ISP for resident #3.
Plan of Correction:	ISP updates were signed on 7/13/19. All ISPs will be signed by the resident or their legal representative as they are updated. Administrator or designee will audit resident files monthly to ensure ISPs are signed as they are updated.
Standard #:	22VAC40-73-550-C
Description:	Based on record review and interview, the facility failed to ensure that a resident of an assisted living had the rights and responsibilities as provided in 63.2-1808 of the Code of Virginia to be free from physical abuse. Evidence: 1. Resident #1 was admitted on 7-07-17. The Uniform Assessment Instrument dated 5-14-19 documented resident?s behavior pattern as ?Abusive/Aggressive/Disruptive ? Weekly or more.? Additionally, resident?s Individualized Service Plan dated 5-27-19 documents for behavior pattern ?Resident displays agitation/anxiety and resist ADL care. If he is resisting ADL care, leave him in a safe manner and attempt task later.? 2. Resident #1?s record contained documentation that revealed an incident occurred 5-25-19 where the resident?s arms were tightly held by direct care staff, resulting in skin tears. `Service Notes? documented on 5-25-19 at 9:00 a.m. documented: ?Resident sustained 4 skin tears to right and left forearm during AM care today. Appropriate management, spouse, and hospice made aware. Skin tears cleansed and dressed. Resident in room resting at this time. Will continue to monitor.? 3. Staff #2 confirmed direct care staff had caused injury to resident during care based on direct care staff?s interview with staff #2.
Plan of Correction:	Mennowood Retirement Community discovered an incidence of potential abuse and immediately self-reported to the Virginia Department of Social Services. Necessary disciplinary actions were taken against the staff member involved. All staff members were inserviced on managing difficult behaviors. All staff members will receive ongoing training on managing difficult behaviors.