VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Indian River Assisted Living
1012 Justis Street
Chesapeake, VA 23325
(757) 523-4659

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Oct. 10, 2019 and Dec. 27, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

Licensing Representatives conducted an unannounced monitoring inspection on October 10, 2019 from 9:27 a.m. to 3:28 p.m. and December 27, 2019 from 8:36 a.m. to 1:58 p.m. There were 95 residents in care on October 10, 2019, and 101 residents in care on December 27, 2019. The following topics were discussed: organization and timeliness of records, physicians? completion of resident physical exam forms, and services on individualized service plans. Please submit your ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it within 10 calendar days. The plan of correction must indicate how the violation will be or has been corrected. The plan of correction must include: 1. Step(s) to correct the noncompliance with the standard(s) 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative measures. If you have any questions, please contact your inspector Alexandra Poulter at 757-613-5133 or alexandra.poulter@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-250-C
Description:	Based on record review and interview, the facility failed to ensure personal and social data to be maintained on staff and included in the staff record included verification that the staff person has received a copy of his current job description. Evidence: 1. During staff record review on 12-27-19, staff #4?s record contained a job description that was not signed nor was an acknowledgment of receipt in the record. 2. Staff #3 observed and confirmed staff #4?s record did not include verification that the staff had received a copy of his current job description.
Plan of Correction:	All new hire paperwork will be completed upon hire. The Administrator or her designee will audit all employee charts to ensure all employee files have completed paperwork. Additionally, the Administrator or her designee will make sure all new hire paperwork is completed on future hires prior to the employee starting work.
Standard #:	22VAC40-73-350-B
Description:	Based on record review and interview, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and documented in the resident?s record that this was ascertained and the date the information was obtained. Evidence: 1. During record review on 12-27-19, resident #3 admitted on 11-26-19. Resident #3?s sex offender screening was obtained during the inspection on 12-27-19. 2. Staff #3 observed and confirmed resident #3?s sex offender screening was not completed prior to admission and the date completed was 12-27-19.
Plan of Correction:	All admissions will have a sex offender registry check completed before admission. The Administrator or her designee will ascertain that all future referrals have the sex offender registry check completed before or at the time the referral assessment is scheduled.
Standard #:	22VAC40-73-430-H-1
Description:	Based on record review and interview, the facility failed to ensure that at the time of discharge, the assisted living facility provided to the resident, and as appropriate, legal representative and designated contact person a dated statement signed by the administrator that contained the name of legal representative and date of discharge notification provided, actions taken by the facility to assist the resident in the discharge and relocation process, and the resident?s destination. Evidence: 1. During review of resident #4?s Discharge Notification and Statement form on 12-27-19, the form was left blank for the following areas: a. Date of discharge notification to legal representative, b. Name of legal representative, c. Actions taken by the facility to assist the resident in the discharge and relocation process, d. Destination address, and e. Date discharge statement was provided to the resident, and as appropriate, legal representative and designated contact person (specify to whom provided). 2. Staff #3 observed and confirmed the aforementioned areas were not completed on resident #4?s Discharge Notification and Statement.
Plan of Correction:	The Administrator will make sure that in the future the discharge statement is completed fully for all community initiated discharges. The Administrator will assist any residents that are given discharge notices with the relocation process and document their efforts.
Standard #:	22VAC40-73-660-B
Description:	Based on observation, record review, and interview, the facility failed to ensure a resident may be permitted to keep his own medication in an out-of-sight place in his room if the Uniform Assessment Instrument (UAI) has indicated that the resident is capable of self-administering medication. Evidence: 1. During review of resident #3?s record on 12-27-19, the UAI dated 11-21-19 documented medications are administered/monitored by lay person. Resident #3?s Report of Resident Physical Examination documented resident has short term memory loss. 2. During the facility tour with staff #3 on 12-27-19, containers of Neosporin and Medline Skin Integrity Wound Cleanser were observed on the nightstand in resident #3?s room. 3. Additionally, resident #3?s record did not contain orders for the Neosporin or Wound Cleanser. 4. Staff #3 observed and confirmed resident #3 had medications in the room, and resident #3 is dependent in medication administration.
Plan of Correction:	Rooms will be checked weekly for any OTC meds or supplies. If found, staff are to discuss with Resident Care Coordinator and/or Administrator about resident?s UAI/ISP and ability to self-administer medications. Residents who do not have Physician Orders and/or the ability to self-administer medications will not be allowed to keep medications at bedside per community policy.
Standard #:	22VAC40-73-680-D
Description:	Based on observation, record review, and interview, the facility failed to ensure medications were administered in accordance with the physician?s instructions. Evidence: 1. During medication administration observation on 10-10-19, resident #1 was administered Divalproex 500 mg tab at approximately 11:45 a.m. by staff #1. 2. Resident #1 physician?s orders dated 07-01-19 documented the medication is to be administered three times daily with meals; however, as of 12:19 p.m. on 10-10-19, resident #1 had not received a meal. 3. During review of resident #2?s October 2019 Medication Administration Record (MAR) on 12-27-19, the following medications were documented as administered on 10-29-19: Amlodipine Besylate 10 mg, Aspirin 81 mg, Metformin HCL 500 mg, and Omeprazole DR 40 mg. All four medications were discontinued on 10-28-19 as documented on physician?s orders dated 11-01-19. 4. Staff #2 observed and confirmed the aforementioned medication for resident #1 was not given with meals per the physician?s instructions. Staff #3 confirmed resident #2?s medications were administered on 10-29-19.
Plan of Correction:	Administrator to review with Medication staff time frames for delivering medications. For example, if a medication is ordered with meals it is to be given within 30 minutes of meal service. Medication staff and dietary staff to work in better coordination if meals are to be served late. Medication orders are to be immediately updated on MAR when received at the community. If medications are discontinued they are to be taken off of the MAR and removed from the cart when orders are received.
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview, the facility failed to ensure the interior of the building was maintained in good repair and kept clean. Evidence: 1. During a tour of the facility with staff #3 on 12-27-19, the following areas were observed not to be maintained in good repair and/or kept clean: a. Men's East bathroom contained black substance in the floor and wall tiling grout of the shower located between the sink and the shower, spanning approximately two feet in length. b. East Wall hallway spanning had black scuff marks along the bottom portion of the wall and resident room doors, spanning the entire length of the hallway where resident rooms are located. c. South Hall TV Lounge, had brown staining and peeling wallpaper across the far wall from the entrance door. 2. Staff #3 observed and confirmed the aforementioned areas were not maintained in good repair and/or kept clean.
Plan of Correction:	The community will be routinely inspected by the housekeeping and maintenance staff. The housekeeping and maintenance staff will collaborate with the Administrator for any needed on-going repairs and cleaning. The areas identified on survey will be cleaned or repaired as needed to keep the community in good repair.