VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cave Creek ALF
8088 Lee Highway
Troutville, VA 24175
(540) 992-4599

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: Oct. 9, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 SANCTIONS.

Comments:

The LI for Cave Creek conducted an unannounced renewal study at the facility on 10/9/2019 under the supervision of the LA and noted 28 residents to be in care. Resident and staff records as well as other forms of facility documentation were reviewed and interviews were conducted with residents and staff. The morning medication pass and the mid day meals were observed. Please respond with your plan of correction within 10 days of receipt of this notice. IF you have any questions please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-325-A
Description:	Based on a review of resident records, the facility failed to complete a fall risk rating by the time the comprehensive individualized service plan (ISP) is completed. EVIDENCE: 1. Resident 2 was admitted 03/14/2019 and the comprehensive ISP was completed on 03/14/2019; however, as of the date of inspection, a fall risk rating had not been completed for this resident.
Plan of Correction:	A fall risk rating was completed and placed in file for resident 2.
Standard #:	22VAC40-73-640-A
Description:	Based on observations of the facility medication cart and resident record reviews, the facility failed to follow their medication management plan. EVIDENCE: 1. A Lantus Insulin Pen was observed open in the medication cart on the day of inspection for resident 10. The pen did not contain an open date to ensure proper disposal within 28 of opening per manufacturers instructions. The facility medication management plan has documentation to check expiration dates prior to administering and to never use outdated medications. 2. The October 2019 medication administration record (MAR) for resident 5 has documentation that the resident is refusing to wear physician order oxygen on numerous occasions. There is no documentation that the individual responsible for notifying the residents physician of these refusals has contacted the physician to make them aware.
Plan of Correction:	A medication administration and documentation review was conducted with all medication aides by the administrator.
Standard #:	22VAC40-73-700-5
Description:	Based on a review of staff records, the facility to ensure that all staff direct care responsible for assisting residents who use oxygen supplies have had training or instruction in the use and maintenance of resident-specific equipment. EVIDENCE: 1. The record for staff person 3 does not have documentation that the employee has had any training with the use and maintenance of resident specific equipment. This staff persons initials are noted numerous times through September and October 2019 on the facility oxygen therapy check list as checking residents use use oxygen in the facility.
Plan of Correction:	A review and documentation of the use and maintenance of resident specific equipment will be completed.
Standard #:	22VAC40-73-925-B
Description:	Based on observation, the facility failed to ensure that all common hand-washing sinks had paper towels or an air dryer for hand washing. EVIDENCE: 1. No paper towels or air dryer were available by the hand-washing sink in the bathroom between rooms 3 and 4.
Plan of Correction:	paper towels were placed at hand-washing sink by housekeeper.