VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heart & Soul III ALF
611 19th Street
Newport news, VA 23607
(757) 240-4282

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: Nov. 7, 2019 , Dec. 2, 2019 and Dec. 10, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Two Representatives with the Division of Licensing conducted an unannounced, non-mandated, monitoring inspection on 11/07/2019 from approximately 9:20am to approximately 11:29am,12/02/2019 from approximately 11:42am to approximately 12:47am and 12/07/2019 at approximately 9:30am. At the point of entrance on 11/07/2019 the facility Administrator initially denied Licencing Inspector's access to documentation. Areas of non-compliance are found within this violation notice. Please complete the "plan or correction" and "date to be corrected" for each violation cited on the violation notice and return to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring preventative. Please contact the facility Licensing Inspector Kimberly Rodriguez at 804-396-5696 or by email at kimberly.rodriguez@dss.virginia.gov for additional questions or concerns.

Violations:

Standard #:	22VAC40-73-460-B
Description:	Based on phone interview, resident record review and staff interviews, the facility failed to ensure care provision and service delivery shall be resident-centered to the maximum extent possible and include prompt response by staff to resident needs as reasonable to the circumstances. Evidence #1: While conducting a phone interview with staff #4 on 11/19/2019 at approximately 12:09pm staff #4 informed that, "resident #1 was heard coughing and when staff #4 went to check, resident #1 was unresponsive." Staff #4 informed that staff #2 was contacted and staff #4 was directed to contact 911. Based on statement during the phone interview with staff #4, staff #4 did not perform Certified Pulmonary Resuscitation. The Licensing Inspector asked why Certified Pulmonary Resuscitation was not initiated by the facility staff and staff informed, " that the staff #4 would not have been able to remove the resident from the wheelchair". Evidence #2: While Interviewing staff #2 on 12/10/2019, staff #2 informed, " When a resident is found non-responsive staff are to follow protocal, by calling 911 and beginning Certified Pulmonary Resuscitation". Evidence #3: Resident #1's social data sheet documented that resident #1 was a full code as evidenced by photos provided. Evidence #4: Resident #1's record contained a "Do Not Resuscitate form" not signed by a physician, that documented in handwriting, " I want to be resuscitated" and was signed by resident #1 as evidenced by photos provided.
Plan of Correction:	460.B--WILL BE OR HAS BEEN CORRECTED: Training is scheduled on February 4, 2020. STEPS TO CORRECT: Staff training on violations received, to include how to give CPR to a resident in a chair and/or wheelchair will occur or how to remove them from the chair to the floor and administer CPR. MEASURES TO PREVENT THE NONCOMPLIANCE: During our next staff meeting, we will ask for special concerns from the staff regarding CPR. Scenarios and/or role playing are utilized. During our next staff training/meeting, a CPR instructor will demonstrate how to move residents safely during emergencies. RESPONSIBLE PERSON FOR IMPLEMENTING EACH STEP AND/ORMONITORING PREVENTATIVE. The Administrator who is a CPR Instructor will document demonstrations of staff and will make herself available/accessible to staff for any concerns or questions that they may have.
Standard #:	22VAC40-73-930-A
Description:	Based on observation of the facility physical plant the facility failed to ensure the assisted living has a signaling device that alerts direct care staff that the resident needs assistance. Evidence: On 12/10/2019 with staff #3, it was observed that the call bell light outside of resident room #101 did not turn on when the call bell system was activated, as evidenced by photo provided.
Plan of Correction:	Not available online. Contact Inspector for more information.