VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Pearl at Watkins Centre
650 Watkins Centre Parkway
Midlothian, VA 23112
(804) 893-0067

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: Oct. 24, 2019

Complaint Related: Yes

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

Technical Assistance:

460.A The facility shall assume general responsibility for the health, safety and well being of residents. This includes monitoring of doors, visitors and residents.

Comments:

An unannounced inspection was completed at the facility on 10/24/2019 to investigate a complaint in regards to resident supervision and safety. The complaint was determined to be valid based on a review of facility documentation, and interviews with facility staff, a resident and the resident's family member.Please complete the "plan of correction" and "date to be corrected" for the violation cited on the violation notice and return to the Inspector within 10 days. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the non-compliance with the standard, 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). See violation notice for non-compliance The provider's responses for the "plan of correction" were not received as of 11/18/2019 and will not appear on this Violation Notice."

Violations:

Standard #:	22VAC40-73-150-C
Complaint related:	Yes
Description:	A. Based on the review of a resident's file and the facility's daily log, interviews with the resident, resident's family member and staff, the facility's administrator failed to ensure that care is provided to the residents in a manner that protects their health, safety and well-being. Evidence: Two licensing inspectors conducted an inspection at the facility on 10/24/2019 to investigate a complaint that a resident (# 1),who is a female, did not feel safe at the facility due to a male resident (# 2) entering her room on two occasions while she was sleeping and getting into her bed without her knowledge or permission. Reported occasion # 1 - Resident # 2 was found in the bed of resident # 1 while the resident was sleeping by a day visitor to the facility. Resident # 1 stated to the two inspectors during an interview on 10/24/2019 that she could not recall the exact date of the incident, but does recall that the incident took place "in late September or early October 2019". Reported occasion # 2 - Resident # 2 was found in the bed of resident # 1 while the resident was sleeping by a staff member during morning rounds. Staff documented in the Daily Log on 10/7/2019 at 7:28 am, "Resident (#2) was found in another resident (#1) room laying across her bed. Resident (#1) was unaware that (resident 2) was in her room. Med Tech helped him out of her room and back into his room" 1.During an interview with two licensing staff on 10/24/2019, resident #1 stated "I do not feel safe", "it is unsettling". 2.During a telephone interview on 10/15/2019 with the licensing inspector, the resident's family member reported that the resident had shared that she does not feel safe at the facility due to a man entering her room uninvited on two occasions and getting in her bed while she is sleeping. 3. Staff documented in the Daily Log on 10/8/2019 at 12:56 am, "while doing rounds resident on edge, she kept thinking I was another resident, I reassured her we would keep monitoring her to make sure she is safe". 4. The resident and the family member reported that facility staff and administrator were made aware of the two incidents and have not put any measures in place to ensure her safety and/or alleviate her fears.The resident could not recall the dates of her conversation with the administrator, the family member reported his conversation with the administrator took place "a few days" prior to 10/9/2019 and the administrator's responses were "lock the door", "everyone else lock themselves in at night" and " Go ahead and make a complaint, I am going on vacation!? B. Based on the review of a resident's file and a review of previous inspections conducted during the current licenses period, the facility's administrator failed to ensure the development, implementation and monitoring of an individualized service plan for each resident. Evidence: Facility has been cited four times, including at this inspection, for noncompliance with the individualized service plans (on 5/2/2019, 6/25/2019, and 7/25/2019).
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	A. Based on a review of the individualized service plan (ISP) for one resident on 10/24/2019, a comprehensive service plan was not completed within 30 days after admission. Evidence: The documented admission date for resident # 2 is 8/1/2019. Licensing staff requested and was provided the individualized service plan (ISP) for resident # 2. The ISP provided by facility staff was a preliminary (ISP) completed on 7/25/2019. A comprehensive ISP was not provided. **This is a repeat violation that has been cited twice during previous inspections at the facility on 5/2/2019, 6/25/2019 and 7/25/2019.** B. Based on a review of the individualized service plan (ISP) for resident # 2 on 10/24/2019, the ISP described services to be provided for needs that were not identified and/or did not describe identified needs. Evidence: 1. The ISP had an oxygen therapy goal dated 7/25/2019 that stated " Oxygen per physician orders, staff to monitor and assist with nasal cannula as needed". However, the section of the ISP that described needs stated that oxygen therapy was not a need and was checked "No". 2. The ISP stated "Staff will provide verbal cue and redirect in a calm, clear positive voice. Staff will redirect to decrease episodes of disruptive behavior". However, (a) the section of the ISP that described needs stated that there were no disruptive behaviors and was checked "No", (b) the admission note dated 8/1/2019 stated "dementia w/o behavioral disturbances", and (c) the uniform assessment instrument (UAI) dated 7/25/2019 and updated 9/1/2019 does not document any inappropriate behavior. 3. The ISP identifies walking as a need, states "wheelchair, walker, cane, scooter available at all times", and "will use utilize assistive devices as required during walking/wheeling/stair climbing". However, (a) the admission notes dated 8/1/2019 state"ambulating with no assist devices" and (b) the UAI dated 7/25/2019 and updated 9/1/2019 documents that resident does not need help with walking or mobility.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-930-D
Complaint related:	No
Description:	Based on a review of the service plan for resident # 2, the individualized service plan does not comply with 22 VAC 40-73-930.D.3 of the regulations in addressing frequency of rounds. Evidence: The ISP dated 7/25/2019 for resident # 2 does not address frequency of rounds at night, once resident has gone to bed.
Plan of Correction:	Not available online. Contact Inspector for more information.