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: Nov. 14, 2019

Complaint Related: Yes

Areas Reviewed:

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

Comments:

An unannounced complaint inspection was conducted at the facility on 11/4/2019 from 9:30 am to 10:15 am to investigate an allegation that some areas of the facility did not have heat. The allegation was determined to be valid based on an inspection of the facility and communication with residents in care.The facility provides care to individuals who have a serious cognitive impairment with an inability to recognized danger or protect their own safety and welfare. Violations were cited due to the facility's failure in notifying the Department and local officials of the situation and the risk to residents in care. 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.

Violations:

Standard #:	22VAC40-73-40-A
Complaint related:	No
Description:	Based on inspections at the facility on 7/25/2019, 10/24/2019 and 11/14/2019, the licensee failed to ensure compliance with all regulations for licensed assisted living facilities. Evidence: During the first six months of the current license period, there has been six inspections and ten violations of the Standards for Licensed Assisted Living Facilities. Seven violations placed residents at a high risk of health safety and welfare. 1. 7/25/2019 - A complaint investigation was conducted at the facility. Three violations were found in the areas of resident rights, access to the building and resident supervision and care. One violation in the area of resident supervision and care was a high risk violation. 2. 8/20/2019 - A monitoring inspection was conducted at the facility. One violation was found in the area of approval for placement in a secure environment. 3. 10/24/2019 - A complaint investigation was conducted at the facility. The investigation found that the allegations were valid. Three violations were found in the areas of individualized service plans, frequency of rounds, administrator responsibilities. Two of the violations in the areas of administrator responsibilities and individualized service plans were high risk violations.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on an inspection at the facility on 11/14/2019, it was found that the facility failed to report to the regional licensing office within 24 hours a major incident that negatively affected the health, safety and welfare of residents in care. Evidence: The facility's administrator disclosed when asked that she learned of problems with the heating system six days ago on Friday, November 8, 2019 and that a report was not made to the regional licensing office.
Plan of Correction:	ED (Executive Director) to ensure that things that negatively affect our residents is communicated to our licensing office.
Standard #:	22VAC40-73-150-C
Complaint related:	Yes
Description:	Based on an inspection at the facility on 11/14/2019, the administrator failed to ensure that care is provided to residents in a manner that protects their health, safety, and well-being. Evidence: Licensing staff conducted an inspection at the facility on 11/14/2019 to investigate an allegation that some areas of the facility have been without heat since 11/8/2019. During the building inspection, several residents reported that they were cold and one was observed in bed with two heavy blankets, a jacket and head covering. (picture taken). The outside temperatures according to accuweather.com were at a low of 27 degrees on 11/8/19, 21 degrees on 11/9/19, 26 degrees on 11/10/19, 37 degrees on 11/12/19, and 26 degrees on 11/13/19. 1. The facility's administrator was aware of problems with the heating system on Friday, November 8, 2019 and failed to put acceptable measures in place to ensure the health, safety and welfare of residents in care. 3. Local Adult Protective Service (APS) arrived on site on 11/14/2019 to investigate the lack of heat in some areas of the building. APS contacted the Central Region licensing office and informed the licensing administrator that the facility's administrator stated that she did not know what kind of approval is needed from the fire authority. APS initiated a phone call to the local fire authorities who arrived on site shortly thereafter to examine the space heaters. 4. The facility was directed by the local fire authorities to remove the space heaters as they are a violation of the fire code. 5. A plan to protect residents from heat-related illnesses in the event of loss of heat due to emergency situations or malfunctioning or broken equipment was requested and never received. This is a repeat violation that was cited previously at an inspection on 10/24/2019
Plan of Correction:	On 11/14/19 RFD and FD corrected airflow deficiencies by correcting the air duct dampers by opening for proper air flow. We identified additional thermostat problem and corrected. After this we contacted Howells heating and air and collaborated with us to ensure deficiency was corrected and all were resolved. Space heaters were in place at the time however once advised they couldn't be in there they were removed. On 11/14/19 the information requested was scanned and sent to our inspector.
Standard #:	22VAC40-73-880-B
Complaint related:	Yes
Description:	Based on an inspection at the facility and an interview with the administrator of the facility, the facility did not secure approval from state or local building or fire authorities to using space heaters for heat in the event of lost of heat or a similar emergency. Evidence: Licensing staff completed an inspection at the facility on 11/14/2019 to investigate an allegation that the heating system was not working in some areas of the building. Space heaters were found in resident rooms # 1 and # 2. (pictures taken) The administrator stated to licensing staff that approval to use the space heaters had not been obtained from local fire or building authorities.
Plan of Correction:	On 11/14/19 RFD and FD corrected airflow deficiencies by correcting the air duct dampers by opening for proper air flow. We identified additional thermostat problem and corrected.