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Golden Years Assisted Living Facility, Inc.
40 Hunt Club Boulevard
Hampton, VA 23666
(757) 825-2425

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

Inspection Date: Aug. 23, 2019

Complaint Related: No

Areas Reviewed:
22VAC40-73 PERSONNEL
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
22VAC40-73 BUILDING AND GROUNDS
22VAC40-73 EMERGENCY PREPAREDNESS

Comments:
An unannounced focused IPOC monitoring visit was conducted by two Licensing Inspectors from the Eastern Regional Office and Peninsula Licensing Office on 08-23-2019 from 9:45 AM to 2:08 PM. There were 79 residents in care at the time of the inspection. A tour of the exterior and interior of the building was conducted.5 staff records and the criminal background checks and sworn disclosures were reviewed for all new hires since the previous inspection, and 2 resident records were reviewed. The following was discussed with the Administrator during the inspection: Buildings and Grounds, AC units, side rails, and staff records. The facility received violations ?under? Personnel, Resident Care and Related Services, Buildings and Grounds, and Emergency Preparedness. The areas of noncompliance were discussed with the Administrator throughout the inspection and during the exit interview.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 on 10-03-2019.

Violations:
Standard #: 22VAC40-73-260-A
Description: Based on record review and interview, the facility failed to ensure each direct care staff member maintained current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
Evidence:
1. During staff #4?s record review with staff #1 and staff #3, staff #4 was hired as a Certified Nurse Aide (CNA) on 06-27-2019. Staff #1 and staff #3 could not provide documentation verifying staff #4 was currently certified in first aid from one of the approved providers.
2. During interview, staff #1 and staff #3 acknowledged staff #4 was not currently certified in first aid.

Plan of Correction: Quarterly CPR/ First Aid will be scheduled to ensure all new hires are certified within 120 days of hire and current employees are kept current.

Standard #: 22VAC40-73-660-B
Description: Based on observation, record review, and interview, the facility failed to ensure a resident permitted to keep their own medication in an out-of-sight place in their room if the Uniform Assessment Instrument (UAI) has indicated that the resident is capable of self-administering medication.

1. During the tour of the facility with staff #1 and staff #2, resident #1 was observed retrieving a bottle of Glucerna from a mini refrigerator located in the resident?s room. An unopened box of Basaglar Kwikpens was also observed in the refrigerator.
2. During resident #1?s record review, the most current UAI on file dated 03-29-2019 documented for medications to be administered by professional nursing staff. The UAI did not document that the resident was capable of self-administering medications.
3. During interview, staff #1 and staff #2 acknowledged the Glucerna and Baglasar Kwikpens in the mini refrigerator of resident #1?s room and acknowledged that the resident was not permitted to keep medications in their room based on the current UAI.

Plan of Correction: Explained to resident samples given by doctor must be turned in to medication aides for proper documentation and storage. To avoid meds in personal refrigerators, medication aides will be checking the personal refrigerators weekly to prevent injury and future violations.

Standard #: 22VAC40-73-860-I
Description: Based on observation and interview, the facility failed to store cleaning supplies and other hazardous materials in a locked area.
Evidence:
1. During the tour of the facility with staff #1 and staff #2, the following cleaning supplies and other hazardous materials were observed unattended and were left in an unlocked area:
a. The maintenance room was open, containing a bottle of charcoal lighter fluid, Formula 815MV SC industrial strength cleaner/degreaser, Grout and tile cleaner, and Home Defense insect killer.
b. The laundry room was open, containing a bottle of furniture polish spray, and awesome bleach.
2. During interview, staff #1 and staff #2 acknowledged the aforementioned chemicals and hazardous materials were left unlocked and unattended in the maintenance room and laundry room.

Plan of Correction: Automatic door lock system on laundry for added security. Laundry, Housekeeping and nursing all have keys so that chemicals needed for daily duties can be accessed when needed to prevent doors from being unlocked to prevent injury and future violations.

Standard #: 22VAC40-73-870-A
Description: Based on observation and interview, the facility failed to ensure the interior and exterior of the facility is maintained in good repair, kept clean, and is free of rubbish.
Evidence:
1. During the tour of the facility with staff #1, staff #2, and staff #3, the following areas observed were not in good repair, kept clean, or free of rubbish:
A. In the backyard area accessible to residents- 1. Approximately ?? of the board on the deck floor was detached from the foundation; 2. Approximately 6 large plywood boards were leaning against the fence with rusted nails sticking out; 3. A hole approximately 8? in diameter and approximately 12? deep was located on the ground near a white wicker loveseat; 5. Additionally, there was a hole in the ground located by the exit door near the facility?s gift shop that was approximately 30? in length and 18? in width and was filled with water.
B. Inside of the facility- 1. The toilet paper holder in room #34 was broken off of the wall and was on top of the bathroom countertop; 2. Dead flies and ants were on the floor in room #1 and dead ants were on the floor in room #38.
2. During interview, staff #1, staff #2, and staff #3 acknowledged the aforementioned areas were not in good repair, kept clean, or free of rubbish.

Plan of Correction: Plywood boards have been removed. Deck board repaired. 70+feet of fence has been installed. Hole was filled with dirt. Area near exit door has been replaced with concrete footing to ensure safety when used as exit. New toilet paper dispensers are being installed to accommodate larger rolls of toilet paper and placed in higher position for easy access. Housekeeping to monitor rooms, all edibles must be kept in container to prevent bugs from the area. Housekeepers will reports to Director of Operations.

Standard #: 22VAC40-73-870-E
Description: Based on observation and interview, the facility failed to ensure all furnishings and fixtures including furniture, window coverings, toilets, and showers are kept clean and in good repair.
Evidence:
1. During the tour of the facility with staff #1, staff #2, and staff #3, the following items observed were not clean or in good repair:
A. In the backyard area accessible to residents- 1. The wooden arm rest was broken off the chair; 2. Approximately 75% of the vinyl seat covering on a chair was torn and exposed the foam padding of the seat; 3. Approximately 50% of the front part of the red wooden bench was splintered, split, and detached from the bench; 4. A metal framed chair was missing approximately 50% of the rubber seat slats and cushions, leaving the seat without a base; 5. Approximately 25% of the armrest on the white wicker bench was missing.
B. Inside of the facility- 1. A slat on the blinds was broken in room #17; 2. 2 out of 3 showers located in the women?s bathroom near room #17 were missing drain covers; 3. There was a brown like substance located on the rim of the toilets located in the women?s bathroom near room #17 and in room #34; 4. In room #45, one of the drawers to the dresser was missing; 5. In room #42, the face of the nightstand drawer was missing.
2. During interview, staff #1, staff #2, and staff #3 acknowledged the aforementioned furnishings and fixtures were not kept clean or in good repair.

Plan of Correction: All damaged broken chairs/benches have been replaced with wrought iron benches.
Curtains and fixtures are replacing blinds in resident?s rooms. Completed corrected dated 11-01-2019
Missing drain covers have been replaced. Dresser drawers have been repaired/replaced. Needed repairs to be reported to Director of Operations. Weekly rounds to be make by Director of Operations and maintenance for needed repairs.

Standard #: 22VAC40-73-890-B
Description: Based on observation and interview, the facility failed to ensure the interior area was adequately lighted for the safety of the residents.
Evidence:
1. During the tour of the facility with staff #1, staff #2, and staff #3, when the switch was placed in the on position, 8 out of 14 ceiling lights located in the dining room did not turn on, and 2 out of 4 lights in the television room on the back hallway did not turn on. Both rooms observed were dimly lit and did not provide adequate lighting for the safety of the residents.
2. During interview, staff #1, staff #2, and staff #3 acknowledged the lights in the aforementioned rooms were not working and did not provide adequate lighting for the safety of the residents.

Plan of Correction: Lights have been replaced if needed, covers have been ordered. Director of Operations and maintenance will monitor all areas for lighting in common areas and resident rooms.

Standard #: 22VAC40-73-890-C
Description: Based on observation and interview, the facility failed to ensure coverings were used for lights when necessary to reduce glare.
Evidence:
1. During the tour of the facility with staff #1, staff #2, and staff #3, the light covers were missing on the ceiling near room #11 and over each residents bed in room #45.
2. During interview, staff #1, staff #2, and staff #3 acknowledged the aforementioned lights did not include coverings.

Plan of Correction: Lights have been replaced if needed, covers have been ordered. Director of Operations and maintenance will monitor all areas for lighting in common areas and resident rooms.

Standard #: 22VAC40-73-960-B
Description: Based on observation and interview, the facility failed to ensure the fire and emergency evacuation drawing posted on each floor of the building used by residents showed the areas of refuge and assembly areas.
Evidence:
1. During the tour of the facility with staff #1, the fire and emergency evacuation drawings located by the gift shop and by the television room on the back hallway did not include the areas of refuge and assembly areas.
2. During interview, staff #1 acknowledged the areas of refuge and assembly areas were not included on the aforementioned fire and emergency evacuation drawings.

Plan of Correction: Assembly area added to emergency evacuation drawings. Future drawings will be reviewed for room corrections etc.- by Administration.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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