VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Haven Assisted Living@Cold Harbor
6367 Cold Harbor Road
Mechanicsville, VA 23111
(804) 779-4847

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Feb. 4, 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:

On 02/04/2020 the assigned VDSS inspector conducted a renewal inspection at the facility between the approximate hours of 12:05p.m and 2:28p.m. The facility staff on duty reported eight residents in care. The mid-day medication administration pass was observed. Technical assistance regarding the facility?s medication regimen and documentation was offered to the medication aide as well as a house Manager. Upon the arrival of the inspector the administrator was not on site but two other managers for the Licensee arrived later and assisted with the inspection. Four residents, two staffs and other facility records were reviewed for compliance. House Manager#1 accompanied the inspector during the walk through of the interior of the physical plant. The noncompliance revealed during this renewal inspection was discussed with house Manager #1 and is contained within this report. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and returned it to me within 10 calendar days from today. 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 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 any preventive measure(s). If you have any questions please feel free to contact me at (804)-662-9774 or at Angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on the review of the facility?s medication administration record charting for February 2020 facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Resident #3 Resident #3 The MAR charting for February 2020 notes that the resident is to have blood glucose checks conducted three times a day at meal times. The resident?s physicians? order also provides instructions for the amount of insulin to be administered based on the glucose readings. Upon the arrival of the inspector at the facility on 02/04/2020 the residents were observed sitting at the table awaiting for the lunch meal to be served. The inspector did observe resident #3 eating her lunch time meal. The inspector reviewed the February 2020 MAR and the noncompliance revealed with facility house Manager #1 upon her arrival to the facility. House Manager #1 also observed the photographs taken by the inspector at 12:15p.m on 02/04/2020 as evidence that the facility medication aide had initialed on the facility MAR that the glucose reading was conducted at 1:00p.m. but did not document evidence of what the resident?s blood glucose reading was and whether insulin was administered. During interviews on 02/04/2020 facility house manager #1 stated that facility medication aides are supposed to record the blood glucose readings on the MAR; which the medication aide had not done and that she; house manager #1 would have to contact the medication aide to determine whether the insulin was administered or not.
Plan of Correction:	FACILITY RESPONSE- " Medication aid had checked BS 30 min prior to meal, order per doctor has been corrected to reflect how BS is to be checked and at wha time it is to be given per individual resident since "meal time" may vary from one day to the next slightly."
Standard #:	22VAC40-73-870-A
Description:	Based on observation of the interior of the facility on 02/04/2020 with manager #1, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair. Evidence: As evidenced by the photographs taken on 04/02/2020 the following was observed: A hole was in the wall near bedroom #1 Scuff marks were observed on the door frames of various resident bedrooms and the walls in the hall way leading to resident bedrooms
Plan of Correction:	FACILITY RESPONSE- Home is in process to be renovated and improved in a timely manner."
Standard #:	22VAC40-73-870-E
Description:	Based on observation of the interior of the facility on 02/04/2020 with manager #1, the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. Evidence: As evidence by the photographs taken at the facility on 02/04/2020 a gold couch in the living room of the facility was observed to be worn with peeling fabric.
Plan of Correction:	FACILITY RESPONSE- " All furniture is being replaced as it needs to be replaced."