VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Dickensonville Assisted Living
80 Yahweh Road
Castlewood, VA 24224
(276) 794-7868

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: Jan. 23, 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

Comments:

Two licensing inspectors conducted an unannounced non-mandated monitoring inspection on 01/23/2020 at Dickensonville Assisted Living. The inspection began at 9:30 am and concluded at 1:20 pm. A tour of the building and grounds was conducted. Residents were interviewed. Resident and staff interactions were observed. The noon meal and noon medication pass were observed. Resident and staff files were reviewed. Medication and Medication Administration Records were reviewed. The facility is licensed to provide care to 27 residents, and 23 residents were found to be in care at the time of the inspection. Required postings and the previous inspections were observed to be in place. An exit meeting was held with the administrator and assistant administrator on 01/23/2020 and at that time the opportunity was given to find items that were not readily available in the records. As a result of this inspection, four violations are being cited. A corrective action plan should be developed addressing steps to correct the noncompliance of each standard; for implementing each step and/or monitoring and prevention measures. The "description of action to be taken" for each violation along with the "date to be corrected" must be returned to this licensing office signed and dated within ten calendar days (02/06/2020) of receipt. If you have any questions or concerns please contact your inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on documentation review, the facility failed to provide disclosure to the resident on a form developed by the department. EVIDENCE: 1. Residents #2, #3, and #5 were admitted to the facility on 11/05/2019. Resident #4 was admitted on 12/04/2019. Resident #6 was admitted on 11/06/2019. 2. The facility included a disclosure statement in the files of Residents #2, #3, #4, #5 and #6, however, it was not the most recent form developed and adopted by the department which went into effect 10/2019.
Plan of Correction:	Disclosure statement has been updated to current form. All residents will be given new disclosures to sign. [sic]
Standard #:	22VAC40-73-320-A
Description:	Based on documentation review, the facility failed to include a statement on the admission physical addressing whether or not a resident is or is not capable of self-administering their medication for one resident in the sample of six. EVIDENCE: 1. Resident #6 was admitted to the facility on 11/06/2019. The admission physical was dated 10/17/2019. There was no statement addressing whether the resident was capable or not of self-administering their own medication.
Plan of Correction:	Information will be collected from physician and added to resident chart. In the future administrator will monitor that all information is on physical at admission. [sic]
Standard #:	22VAC40-73-700-1
Description:	Based on review of resident records and physicians orders for oxygen therapy, the facility failed to ensure the physician's order included the oxygen source such as compressed gas or concentrators for one resident. EVIDENCE: 1. Resident # 7 receives oxygen therapy. The physician's order for oxygen therapy for this resident signed on 01/16/2020 states to use oxygen at 3L/min via N/C continuously for breathing. The order did not state the source of the oxygen.
Plan of Correction:	Orders being obtained from physician to state whether oxygen source is from compressed gas or concentrator. Administrator will ensure oxygen sources are listed on orders in the future. [sic]
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during the morning tour of the building, the facility failed to ensure all furnishings including sinks are kept clean and in good repair and condition. EVIDENCE: 1. The sink in the common bathroom located beside the office/Medication room had water standing in it and was very slow to drain.administrator/mediation room had water standing in it and was very slow to drain.
Plan of Correction:	Maintenance has serviced drain in bathroom sink. Administrator will monitor weekly and report any drains that are in need of servicing. [sic]