VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Golden Care Services, LLC
532 Settlers Landing Road
Hampton, VA 23669
(757) 768-6046

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: Aug. 28, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

An unannounced renewal inspection was conducted by two Licensing Representatives on August 28th, 2019 from 6:48 a.m. to 10:31 a.m. There were 6 residents in care. The following was discussed during the inspection: infection control, medication protocol, individualized service plans, training, physician?s orders, and physical plant. Please submit your ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it within 10 calendar days. The plan of correction must indicate how the violation will be or has been corrected. 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 alexandra.poulter@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-100-C-1
Description:	Based on observation and interview, the facility failed to ensure the infection control program was followed by using personal protective equipment, ensuring hand hygiene, and following procedures for blood glucose monitoring practices that are consistent with Centers for Disease Control and Prevention (CDC) recommendations. Evidence: 1. During medication administration observation, the following was observed: a. Staff #1 placed medications in the palm of her hand, and then placed the medications in a cup to administer to resident #1, resident #2, resident #3, and resident #5; b. Staff #1 did not use hand sanitizer or wash hands in between administering medications to four residents; c. Staff #1 did not label diabetic supplies. Staff #1 identified Prodigy diabetic lancets as belonging to resident #1; although observed without labels during a review of the medication cart. Additionally, staff #1 completed a blood sugar check on resident #1 without the use of gloves; and d. Staff #1 administered two drops of Atropine 1% in resident #2?s mouth without using gloves. 2. Staff #1 observed and confirmed the aforementioned evidence.
Plan of Correction:	Administrator has reviewed training as it regards to handwashing/ hand sanitizing protocols for medication. And will ensure appropriate procedures are done during medication passes. Administrator/ medication aides are also scheduled for refresher class on October 28, 2019.
Standard #:	22VAC40-73-160-B
Description:	Based on record review and interview, the facility failed to ensure all licensed administrators continued to meet the continuing education requirements for continued licensure. Evidence: 1. Staff #1 was hired 04-06-15 as the administrator. Review of staff #1?s record documented no continuing education had been completed throughout the duration of their employment. 2. Staff #1 observed and confirmed staff #1 was a direct care staff and their record did not contain documentation of continuing education. Staff #1 stated ?The training log is at home.?
Plan of Correction:	Administrator retrieved training log and has all training documentation on site. Administrator will work on having an electronic back up file of recordings of training.
Standard #:	22VAC40-73-210-B
Description:	Based on record review and interview, the facility failed to ensure all direct care staff attended at least 18 hours of training annually in a facility licensed for both residential and assisted living care. Evidence: 1. Staff #2 was hired 04-04-15 as direct care staff. Review of staff #2?s record documented no training hours had been completed throughout the duration of their employment. 2. Staff #1 observed and confirmed staff #2?s record did not contain any documentation of training hours. Staff #1 stated ?The training log is at home.?
Plan of Correction:	Administrator retrieved training log and has all training documentation on site. Administrator will work on having an electronic back up file of recordings of training
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview, the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs and date identified based upon the uniform assessment instrument (UAI). Evidence: 1. Resident #5 admitted to the facility on 08-12-2016. The most current ISP was dated 08-02-18 and did not include mobility needs as assessed on the UAI dated 08-02-18. 2. Resident #1 admitted to the facility on 10-03-14. The most current ISP was dated 06-28-19 and did not include wandering behaviors as assessed on the UAI dated 06-28-19. 3. Staff #1 observed and confirmed resident #5 requires mobility assistance, and resident #1 has wandering behaviors as assessed on the UAI.
Plan of Correction:	Administrator corrected ISP?s to reflect UAI?s in their current state. Administrator will attend a refresher class to prevent further oversights.
Standard #:	22VAC40-73-680-B
Description:	Based on observation and interview, the facility failed to ensure medications were removed from the pharmacy issued container and administered to the resident by the same staff person, and medications remained in the pharmacy issued container with the prescription label or direction label attached, until administered to the resident. Evidence: 1. Resident #3?s most current Uniform Assessment Instrument documented resident is dependent in medication administration. 2. Resident #3 attends a day program. Staff #1 provided resident #3 Alprazolam 0.5 mg to take to the day program. The August Medication Administration Record had the second dose of medication scheduled to be administered at 12:00 p.m.; however, the resident was scheduled to be at the day program at that time. 3. Staff #1 observed and confirmed the resident was provided the 12:00 p.m. dose of Alprazolam to take to the day program.
Plan of Correction:	Administrator contacted physician to get appropriate documentation for special circumstances of resident in question to self-administer that medication due to resident attending a day program and staff inability to administer such medication when off premises of the facility. Administrator will make sure to have special order is in hand for any other resident going forward.
Standard #:	22VAC40-73-680-C
Description:	Based on observation, record review, and interview, the facility failed to ensure medications were administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule. Evidence: 1. Resident #1?s Metformin 500 mg was administered at approximately 7:06 a.m. on 08-28-19; however, the August 2019 Medication Administration Record documented the medication is scheduled to be administered at 9:00 a.m. 2. Resident #3?s Clonidine 0.1 mg was administered at approximately 7:12 a.m. on 08-28-19; however, the July 2019 MAR documented the medication is scheduled for 9:00 a.m. 3. Staff #1 observed and confirmed the MAR documented the aforementioned medications were scheduled to be administered at 9:00 a.m. and were administered outside of the facility?s dosing schedule.
Plan of Correction:	All MAR?s and physician orders has been handwritten in and updated with time to reflect the daily routine of residents dosing schedule. All physicians have signed off on all medication times. Administrator will make sure all MAR?s and P O?s following will reflect these times.
Standard #:	22VAC40-73-680-D
Description:	Based on observation and interview, the facility failed to administer medications in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. During medication administration observation, staff #1 administered Atropine 1% under resident #2?s tongue; however, the physician?s order dated 07-29-19 documented the medication is to be administered in the cheek. 2. Staff #1 observed and confirmed the medications weren?t administered in accordance with the order as the Atropine order was for the medication to be administered in resident #?s 2?s cheek.
Plan of Correction:	Administrator contacted physician to get orders to reflect how resident wish to receive medication resulting in physician updating route of medication. Updated orders signed.
Standard #:	22VAC40-73-680-G
Description:	Based on observation and interview, the facility failed to ensure over-the-counter medications remained in the pharmacy issued container, labeled with the resident?s name, or in a pharmacy-issued container, until administered. Evidence: 1. During review of the medication cart, Aspirin, Lubricant eye drops, and Aspercreme with Lidocaine 4% were observed without labels. Staff #1 confirmed the medications belonged to resident #4. 2. Staff #1 observed and confirmed the evidence.
Plan of Correction:	Administrator removed all overflow and excess medication from medication cart and appropriately label all medication to reflect appropriate resident?s that medication belongs to. Administrator will ensure medication is label prior to storage.
Standard #:	22VAC40-73-860-G
Description:	Based on observation and interview, the facility failed to ensure hot water at taps available to residents were maintained within a range of 105?F to 120?F. Evidence: 1. During tour of the facility, water temperatures in the facility were as follows: a. 133?F in the upstairs bathroom sink. b. 126.5?F in the downstairs shower room sink. c. 130.5?F in the downstairs guest bathroom sink. 2. Staff #1 observed and confirmed the temperatures were above the required range.
Plan of Correction:	Administrator called maintenance on the day of state inspection. Maintenance adjusted temperature. Administrator will continue to keep log check and record temperature.
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. Evidence: 1. In the supply/medication room, there was a crack on the wall closest to the door that spanned approximately two feet. 2. In the bedroom directly across from the stairs, there was chipped paint that was quarter-sized in two places on the wall closest to the door. 3. In the farthest bedroom to the right in the hallway, the carpet was separating in a line spanning approximately three feet. 4. Staff #1 observed and confirmed the aforementioned areas were not in good repair during the facility tour of physical plant.
Plan of Correction:	Administrator called maintenance to repair crack on wall 8/31/19 Maintenance painted wall 8/31/19 Maintenance repaired carpet on 8/31/19
Standard #:	22VAC40-73-950-A
Description:	Based on record review and interview, the facility failed to ensure documentation of annual contact with the local emergency coordinator to determine local disaster risks, communitywide plans to address different disasters and emergency situations, and assistance, if any, that the local emergency management office will provide to the facility in an emergency. Evidence: 1. Requested staff #1 to provide documentation of annual contact (or attempts to contact) the local emergency coordinator. 2. Staff #1 confirmed that annual contact (or attempts to contact) the local emergency coordinator had not been made.
Plan of Correction:	Administrator contacted local emergency management office on Sept. 6, 2019. Administrator documented and record information in reference of the call
Standard #:	22VAC40-73-980-C
Description:	Based on observation and interview, the facility failed to ensure that the first aid kit was checked at least monthly to ensure items with expiration dates were not past their expiration dates. Evidence: 1. The facility?s first aid kit contained an expired hand sanitizer with an expiration date of 05-19. 2. There was no documented monthly check to ensure items were not expired in the facility. 3. Staff #1 observed and confirmed the expired item in the first aid kid and the monthly check was not completed for the kit.
Plan of Correction:	Administrator replaced hand sanitizer and recorded date on monthly check sheet. Two staff will check kit to ensure upkeep of items that expire.