VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heart & Soul III ALF
611 19th Street
Newport news, VA 23607
(757) 240-4282

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: Sept. 11, 2019 and Sept. 18, 2019

Complaint Related: No

Areas Reviewed:

s

Comments:

Two Representatives with the Division of Licensing conducted an unannounced, mandated, renewal inspection on 06-11-2019 from approximately 9:26am to 4:44pm and finished the inspection on 09-18-2019 from approximately 5:49am to 8:24am. At the point of entrance the facility had 25 residents in care, in which most were out of the facility during the day. The Licensing Representatives observed the facility physical plant, observed residents during meal times, reviewed 6 resident and 3 staff records, reviewed the facility first aid kit, observed the emergency food supply, observed the facility medication administration pass and interviewed residents and staff. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring preventative measures. Please contact the facility Licensing Inspector Kimberly Rodriguez at Kimberly.rodriguez@dss.virginia.gov or by phone at 804-396-5696

Violations:

Standard #:	22VAC40-73-100-A
Description:	Based on observation of the facility physical plant, the facility failed to implement an infection control program to prevent and control disease and infection that is consistent with federal Centers for Disease Control and Prevention guidelines. (as evidenced by photos provided) Evidence: On 09-11-2019, the women?s restroom shower contained three, non-labeled, soiled wash rags and sponges. The aforementioned information was acknowledged by staff #1 that the sponges and washcloths were not labeled and soiled.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-120-A
Description:	Based on observation, record review, and interview, the facility failed to operate within the terms of the license and comply with any other limitations that the department may prescribe within the context of the regulations. Evidence: 1. On 09-11-2019, the facility provided the Licensing Inspector with the ?What your Inspector Needs From You Today? form which documented that the facility has 1 non-ambulatory resident, who was identified by staff #2 as resident #2. 2. The license issued by the Department of Social Services reads, "All residents must be ambulatory." 3. On 09-11-2019, during resident #2?s record review with staff #1 and staff #2, the ?Clinical Notes? documented the following: A. On 08-01-2019, the resident was admitted to Home Health services for PT and OT to evaluate the resident in the use of/during use of wheelchair. B. On 08-20-2019, ?Home Health worked with pt and staff (staff #5) on w/c to shower transfer bench with slide transfer board. Staff reported he normally gets pt in and out of shower alone. Slide board started coming out during transfer into shower. Very poor positioning on shower bench due to pts C.P. [Cerebral Palsy] resulting in severe increased tone throughout his body, and poor trunk control. Pt needed 2 people to transfer back to power scooter. Pt and staff are at high risk for falls and injuries?? C. On 08-30-2019, ??Pt has a responsibility to notify staff when he needs to be transferred?? D. On 09-06-2019, ??Instructed staff #5 that staff need to assist with all transfers? Pt need 2 people to assist with All transfers due to severe increased tine throughout patients body due to CP?? E. On 09-09-2019,??Pt reported staff #5 assisted him with getting into the W/C and applied the seat belt?? 4. During interview on 09-18-2019, resident #2 stated he can transfer independently; however when observed by the Licensing Inspectors and staff #1 on 09-18-2019, staff #1 had to assist the resident in moving the motorized wheelchair so that the resident could scoot himself into bed. The resident was observed with his legs hanging off of the bed and could not move his legs onto the bed. When the resident attempted to get out of bed, staff #1 had to assist the resident in moving the motorized wheelchair towards the resident?s bed and provided assistance in helping the resident into the wheelchair. Resident was observed by Licensing Inspectors straining to pull himself up by grab bars with only the upper portion of resident's body on the bed. The resident was not able to pull legs onto bed and Licensing Inspector requested staff #1 to stand close to resident for safety. 5. Resident #5's Individualized Service Plan dated 7/12/2019 by the facility addresses the need for human and mechanical help. The need reads, " Staff will physically assist resident in and out of bath tub also rails and shower chair is used".
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-150-F
Description:	Based on facility documentation review, the facility failed to ensure the Administrator served on a full time basis. Evidence: On 9-11-2019 while conducting a tour of the physical plant, documentation showed staff #1 was scheduled to work, 8:00am to 5:00pm, Monday, Wednesday and Saturdays during the month of July, August and September totaling 27 hours per week.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-860-I
Description:	Based on observation and interview, the facility failed to store cleaning supplies in a locked area. ( as evidenced by photos provided) Evidence: 1. On 09-11-2019, during the tour of the facility with Staff #1 and Staff #3, the following cleaning supplies and other hazardous materials were observed unattended and were left in an unlocked area. a. The storage room across from the medication room was open, containing Dust Mop Dust Cloth Treatment cleaner, Raid, Glass & Multi-Surface Cleaner, Paint Thinner, and Ajax with bleach. b. Room #105 (occupied by 3 residents) was labeled as the ?Electric Panel Room? and had an unlocked closet containing 5 boxes (6 bottles per box) of pure bleach. 2. During interview on 09-11-2019, staff #1 and staff #3 acknowledged the aforementioned chemicals were left unlocked and unattended in the storage room and in room #105.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview, the facility failed to ensure the interior of the building was maintained in good repair and kept clean.( as evidenced by photos provided) Evidence: 1. On 09-11-2019, during the tour of the facility with staff #1 and staff #3, the following items observed were not in good repair or kept clean: A. The men?s bathroom located across from room #107, a square tile approximately 4? x 4? was missing on the bathroom floor, and the ceiling vent was dusty. B. The men?s bathroom located across from room #107, sink cabinet was rotted, missing a portion of the base below the cabinet doors. C. The men?s bathroom located across from room #104 contained a ceiling vent that was dusty. D. The ceiling tile located in the hallway near the activity room was bowed and was hanging down; two ceiling tiles above medication room had brown circular stains, and there was brown stain on one ceiling tile and a gap approximately 4? in size in between two ceiling tiles located in the dining room. E. There were dead flies located on the windowsill in room #109 and room #110, and three slats were broken on the blinds in room #109. F. The women?s bathroom tub contained a black substance that ran in between the top portion of the tub and the tile on the wall. G. The women's bathroom door at the base on both sides were dirty. H. Resident room #102 wall above the resident's bed was peeling, with a portion of the paint missing to expose the unpainted wall. I. The men's restroom across from room #104, door was chipped and peeling, with large portions missing to expose unpainted areas. 2. During interview, staff #1 and staff #3 acknowledged the aforementioned areas of the building were not maintained in good repair or kept clean.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-925-B
Description:	Based on observation and interview, the facility failed to ensure common face/hand washing sinks had paper towels or an air dryer. Evidence: 1. On 09-11-2019, during the tour of the facility with staff #1 and staff #3, the men?s bathroom located across from room #107 and the men?s bathroom located across from room #104 did not have paper towels or an air dryer. 2. During interview on 09-11-2019, staff #3 acknowledged there were no paper towels or an air dryer for the residents to dry their hands in the aforementioned bathrooms.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-930-B
Description:	Based on a observation of the facility physical plant and interviews the facility failed to ensure there is a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or that is visible in a manner that permits staff to determine the origin of the signal. (as evidenced by photos provided) Evidence #1: On 09-11-2019 After testing the call bell in resident room #101 that did not work, Licensing Inspector inquired how staff would be alerted regarding call bell. It was observed that the facility signaling system that terminated to a central location was not continuously staffed and was located in a facility room containing cleaning supplies . Based on staff #3 statements, the room was not continuously staffed. Evidence #2: On 09-11-2019 during a tour of the physical plant, it was observed that 4 out of 4 resident restrooms call bell switches were stuck and would not switch on to activate the call bell. Evidence #3: On 09-11-2019 the Licensing Inspector tested the call bell system for room #101. When the Licensing Inspector tested the call bell, the light above the residents bed (located in the resident's room) turned on, however the light used to alert staff outside of the resident?s room, in the facility hallway did not turn on. Staff #1 acknowledged the aforementioned information regarding the bathroom call bell that was stuck as well as the call bell light that did not work outside of resident room #101. Staff #3 acknowledged the aforementioned information regarding the central location not being continuously staffed.
Plan of Correction:	Not available online. Contact Inspector for more information.