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Oakland Manor
1830 Matoax Avenue
Petersburg, VA 23805
(804) 722-3692

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: Jan. 3, 2020

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
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Article 1
Subjectivity
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:
An unannounced mandated renewal inspection was conducted at the facility on 1/3/2020 from approximately 11 am to 1:15 pm. The facility's manager reported one resident in care, the file for that resident was reviewed for compliance along with two staff files and other required documentation.

All new personnel records were reviewed since the last inspection for criminal history record reports and all are in compliance.

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 #: 22VAC40-73-1100-A
Description: Based on a review of one resident file, there was no documentation to support that the order of priority was followed for approval of placement of the resident in a secure environment.

Evidence: The written approval for placement of resident # 1 in a secure environment was signed by a physician. The Approval of Placement form did not document that the order of priority was followed in obtaining the approval.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-73-250-B
Description: Based on a renewal inspection on 1/3/2020, staff files are not retained on site.

Evidence: When staff files were requested for review, facility staff informed the licensing inspector the files are not retained at the facility.

Plan of Correction: Staff records were being audited at the main office during the time of inspection. Administrator will audit charts in the office of the home. Files will continue to be kept in a locked file cabinet.

Standard #: 22VAC40-73-260-A
Description: Based on a review of two staff files, one staff did not have current certification in first aid.

Evidence: A review of the file for staff # 1 found certification for first aid that expired 12/19. The hire date for staff # was noted as 10/19.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-73-440-A
Description: Based on a review of one resident file, the uniform assessment instrument did not document a level of care.

Evidence: The uniform assessment instrument for resident # 1 did not document a level of care. Facility staff was unable to provide this documentation when requested by licensing staff.

Plan of Correction: During initial pre screening, administrator will place all supporting documents upon admission into case management books. Administrator will utilize admission checklist during the admission process to make certain all documents are accessible.

Standard #: 22VAC40-73-450-C
Description: Based on a review of the individualized service plan (ISP) for one resident, the ISP did not address identified needs and other services provided to the resident.

Evidence:
1.The physical examination for resident # 1 dated 11/12/2019 documented "tends to eat rapidly, sometimes to point of choking on his food". The discharge document from CSH dated 11/21/2019 documented "diet is chopped or puree due to tendency to shove food in mouth". The uniform assessment instrument (UAI) for resident # 1 dated 2/19/19 documented under special diet "chopped with nectar thick liquids" and "will eat too fast and put too much in his mouth so requires supervision and some redirection". Special diet (s), meals, eating are not addressed on the resident's services plan.
2. A review of the file for resident # 1 found that the resident receives case management services through the local community services board (CSB) and DAP (Discharge Assistance Program) services A review of the ISP for resident # 1 found that case management and DAP services were not addressed on the resident's ISP.

Plan of Correction: Administrator will complete all ISPs in relevance to information stated on residents' UAI form. Each ISP will be person centered based upon residents' needs. Administrator will include on ISPs individuals special recommendations needed to ensure he/she is receiving the proper care while living in the facility. Administrator will indicate all services residents are receiving outside of the care of the facility.

Standard #: 22VAC40-73-560-E
Description: Based on a renewal inspection on 1/3/2020, resident files are not retained on site.

Evidence: When resident files were requested for review, facility staff informed the licensing inspector the files are not retained at the facility.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-73-560-I
Description: Based on a review of one resident file, a current photograph was not maintained in the resident's file.

Evidence: A current photograph was not found during the file review for resident # 1.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-73-660-A-3
Description: Based on an inspection at the facility, the keys to the medication storage area was in possession of a staff person not authorized to administer medications.

Evidence: Licensing staff requested to review the MARS (medication administration records). Staff # 3 opened the medication cart and accessed the electronic MARs for licensing staff to review. The name of staff # 3 was not found during a name search on the Virginia Board of Health Professions website on 1/13/2020.

Plan of Correction: Not available online. Contact Inspector for more information.

Standard #: 22VAC40-73-680-I
Description: Based on a review of the medication administration on 1/3/2020, the facility has failed to maintain the name, signature and initials of staff administering medication.

Evidence: A review of the paper MARs (medication administration records) provided to licensing staff did not have the name, signature and initials of staff administering medication. Staff was unable to provide a master list in lieu of the the paper MAR documentation when requested by licensing staff.
The documentation was also not available for review on the electronic MAR system.

Plan of Correction: Not available online. Contact Inspector for more information.

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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