VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Atkinson's Retirement Home
4001 Elmswell Drive
Richmond, VA 23223
(804) 236-0175

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: March 10, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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 EMERGENCY PREPAREDNESS 22VAC40-80 COMPLAINT INVESTIGATION.

Comments:

An unannounced complaint investigation was conducted by two licensing representatives on March 10, 2020 from 9:21 a.m. to 12:30 p.m. The complaint was regarding resident care. A census of 5 residents was reported. The following items were reviewed/observed during the complaint investigation: a tour of the facility, facility documentation, review of resident/staff records, staff interviews, and facility postings. The complaint was determined to be valid as some residents require Assisted Living level of care when the facility is licensed for Residential Living level of care. The violations cited are identified in this report. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it to the licensing office within 10 calendar days. Please specify how the violation will be corrected. The plan must contain: 1) step(s) to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation during this inspection. I can be reached at Kimberly.M.Davis@dss.virginia.gov or (804) 662-7578.

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on an interview with the administrator,and a review of the facility's communication log,the facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: The facility failed to report to the regional licensing office the following: - Resident # 6 was transported to the hospital on 2-25-2020 and 3-1-2020. It was also noted in the facility's communication log on 2-25-2020 that Resident # 6 "went out to hospital at 2:45 p.m." and on 3-1-2020 resident "was sent out to hospital". According to documentation from Medical Facility A , the resident had "blood in his foley catheter" on 3-1-2020. -According to the facility communication log, Resident # 1 was sent out to the hospital on 2-19-2020 because he "wasn't feeling well" and on 2-26-2020 "resident called EMT and they picked him up at 7:15 a.m. and he returned at 6:30 p.m." -According to communication log, Resident # 7 "went out to the hospital" on 2-6-2020.
Plan of Correction:	Whenever any resident has to go to the hospital DSS will be notified by phone and fax or email within 24 hours by the administrator or appointed staff if the administrator is not available. The facility will no longer accept residents with a foley catheter.
Standard #:	22VAC40-73-290-A
Complaint related:	No
Description:	Based on a review of facility postings/documentation, the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working on each shift, with an indication of whomever is in charge at any given time. Evidence: When asked for the work schedule for February and March, the administrator searched for a work schedule and was unable to provide one. The administrator stated, "This is what we go by", and provided a copy of the Staff Information Sheet.
Plan of Correction:	An employee work schedule has been posted in clear view of all visitors. Any changes will be posted as needed.
Standard #:	22VAC40-73-310-A
Complaint related:	Yes
Description:	Based on a review of resident records and staff interviews, the facility failed to not admit or retain residents who require a level of care or service for which the facility is not licensed. Evidence: The facility is licensed for residential living level of care only. -Resident # 5 is assessed as Residential Living level of care and needs no help with ADLs, however, administrator stated that a VA nurse comes in Monday through Friday for 2 hours to bathe the resident and that resident requires assistance with mobility. Administrator also stated that resident walks with assistance as well as with a walker. -Resident # 6 was assessed as Residential Living level of care and did not need help with ADLs. However, the resident's report of physical examination indicates that resident "Requires continuous nursing care" and states "recommended that patient have supervision within earshot and should not be allowed to transfer or be mobile without assistance."
Plan of Correction:	Resident # 5 will be relocated within 30 days due to his change in health by administrator. ARH will evaluate and have all residents relocated when their level of care changes to a level other than Level 11.
Standard #:	22VAC40-73-430-H-1
Complaint related:	No
Description:	Based on a review of the record of a discharged resident, the facility failed to complete a Discharge Notification Statement form. Evidence: -Resident #6 was admitted to the hospital on 3-1-2020 and did not return to the facility upon discharge. -Resident #6's record contained a Discharge Notification Statement that was blank.
Plan of Correction:	Administrator will complete a Discharge Statement within 24 hours of discharging a resident.
Standard #:	22VAC40-73-440-H
Complaint related:	Yes
Description:	Based on a review of resident records, the facility failed to ensure that a Uniform Assessment Instrument (UAI) reassessment was completed due to a significant change in the resident's condition to determine whether a resident's needs can continue to be met by the facility. Evidence: -Private pay UAI dated 3-1-2020 for Resident # 5 indicates that the resident needs no help with ADLS and is assessed as Residential Living level of care. However, administrator stated that a VA nurse comes in Monday through Friday for 2 hours to bathe the resident. Facility communication log also states the following: on 2-7-2020, 2-10-2020, 3-2-2020, 3-4-2020, 3-6-2020, 3-7-2020, 3-9-2020, 3-10-2020 resident " is changed and dry". Facility communication log also states on 3-1-2020 that resident is "change and dry." Resident #5 also requires assistance with mobility as administrator stated that resident walks with assistance as well as with a walker. -Private pay UAI dated 12-1-19 for Resident # 6 indicates that the resident did not need help with ADLs and assessed resident as Residential Living level of care. However, the resident's report of physical examination indicates that resident "Requires continuous nursing care" and states "recommended that patient have supervision within earshot and should not be allowed to transfer or be mobile without assistance."
Plan of Correction:	Resident # 5 will be discharged by 4-30-2020 because of his level of care changing. Resident # 6 was discharged already due to his level of care changing. Once level of care for residents does not meet DSS Standards for Level II facilities, the resident will be discharged within 30 days.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on a review of resident records, the facility failed to ensure that each resident's individualized service plan (ISP) contained a written description of to address all identified needs. Evidence: -The Virginia Uniform Assessment Instrument (UAI) for resident #2 dated 5-10-19 indicated the following identified needs that are not addressed on resident's individualized service plan (ISP) dated 7-1-19: mechanical assistance only with ambulation, Tooth or Mouth Problems with a notation of No teeth or dentures under the question "Do you have any problems that make it hard to eat ?", and medication management, and Disorientation- Some spheres, all of the time with the spheres affected noted as "Time" under the Cognitive Function category. - (ISP dated 11-1-19) for Resident # 4 did not indicate whether a staff member needs to be awake at night. -ISPs reviewed for Resident # 1 (ISP dated 11-1-18), Resident #2 (ISP dated 7-1-19), Resident #3 (ISP dated 10-13-19), and Resident # 4 (ISP dated 11-1-19) did not specifically address when and where the services will be provided.
Plan of Correction:	Administrator completed new ISP for Resident # 2, adding all cognitive function categories listed on his UAI to prevent any negative concerns in the future. Resident # 4's ISP was re-written and when and where services will be provided was clearly re-written on ISP for Resident #1, #2, # 3, and # 4.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on a review of resident records, and the facility communication log, the facility failed to ensure that the individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed as the condition of the resident changes. Evidence: - Resident #1's ISP in the resident record was last signed/dated on 11/1/2018. - Resident #1's ISP signed/dated on 11/1/2018 was not updated to reflect the identified need of oxygen. Resident #1 was observed to be using oxygen during the inspection. -Resident #5's ISP signed/dated on 5/1/2019 was not updated to reflect the resident's need for assistance with toileting. The communication log noted that the resident was changed and dried nine times between February 7, 2020 and March 10, 2020.
Plan of Correction:	Oxygen was added to Resident # 1's ISP. Resident # 5 will be discharged in 30 days due to level of care changing.
Standard #:	22VAC40-73-700-1
Complaint related:	No
Description:	Based on the review of a resident's record, the facility failed to ensure it has a valid physician's or other prescriber's order for oxygen therapy. Evidence: The facility did not have a physician's order for oxygen therapy for Resident # 1 who was on oxygen while the inspectors were at the facility.
Plan of Correction:	Resident # 1's doctor faxed an order to the facility for resident's file. In the future, administrator will not accept new residents on oxygen.
Standard #:	22VAC40-73-750-E
Complaint related:	Yes
Description:	Based on a tour of the facility, the facility failed to ensure that each resident's bed linen was in good repair. Evidence: The bed linen on the bed of Resident # 1 was torn in several places and contained some food crumbs as evidenced by photograph taken.
Plan of Correction:	Staff will check the pockets of residents for sharp objects to prevent tears in sheets. Staff will also encourage residents not to drop crumbs while eating in the bed and watching TV.
Standard #:	22VAC40-73-990-A
Complaint related:	Yes
Description:	Based on a review of facility documentation, the facility could not provide a written plan for resident emergencies that addressed procedures for handing medical emergencies, mental health emergencies, procedures for making pertinent medical information and history available to the rescue squad and hospitals, procedures to be followed in the event of a missing resident, and procedures for notifying the regional licensing office. Evidence: Upon request, the administrator did not provide a written plan for resident emergencies. The administrator provided two large binders containing various documents, none of which as a written plan for resident emergencies containing all of the required components of the standard. The binders contained one document with the facility name at the top that stated that Care Aid should "Be able to follow 911 steps in case of an emergency and contact family member and Administrator when needed."
Plan of Correction:	Administrator wrote a new plan for resident emergencies and reviewed the plan with all staff and residents to check for understanding and secure safety habits. Everyone present signed the plan.
Standard #:	22VAC40-73-990-B
Complaint related:	No
Description:	Based on a review of facility documentation, the facility failed to review the procedures in the plan for resident emergencies at least every six months with all staff. Evidence: The facility failed to provide documentation of the review of the procedures for resident emergencies by all staff at least every six months.
Plan of Correction:	Administrator wrote a new plan for procedures for resident emergencies and had all staff review and sign.
Standard #:	22VAC40-73-990-C
Complaint related:	No
Description:	Based on a review of facility documentation, the facility failed to ensure that at least once every six months, all staff currently on duty on each shift participate in an exercise in which the procedures for resident emergencies are practiced. Evidence: The facility provided documentation entitled "6 Months Exercise For Resident Emergency Procedures" dated 3-2-2020, however, no staff names indicating participation were documented, only resident names.
Plan of Correction:	Administrator completed a new exercise for resident emergency procedures and had all staff to sign form to prevent mistakes during emergencies.
Standard #:	22VAC40-80-60-B-2
Complaint related:	No
Description:	Based on a review of facility documentation and collateral documentation obtained, and pursuant to ? 63.2-1712 of the Code of Virginia, the facility failed to act in accordance with the General Procedures and Information for Licensure (22VAC40-80) to ensure that anyone that operates an assisted living facility does not make any report known to be false or untrue to any representative of the commissioner. Evidence: -A Virginia Uniform Assessment Instrument dated 05/10/2019 was received by the licensing inspector on 03/10/2020 from the licensee while on-site at the facility. -Subsequently, a Virginia Uniform Assessment Instrument (UAI) dated 05/10/2019 was obtained by the Department on 03/25/2020 from the Local Department of Social Services. -The report from the local Department of Social Services did not match the report received by licensing from the licensee: (a) Part A 5 Diagnosis & Medical Profile, How do you take your medications? was marked Administered/monitored by lay person on the UAI provided by the local Department of Social Services and marked Without assistance by the UAI provided by the licensee; (b) Part A 12 Client Case Summary notes He is independent with his ADL's but needs assistance with his IADL's and medication management on the UAI provided by the local Department of Social Services. This sentence is missing on the UAI provided by the licensee. -The assessor that completed the UAI verified via email that the version she submitted stated that the resident needs support with medication management and needs assistance with IADL's.
Plan of Correction:	All UAIs will be faxed to VDSS Inspector that are completed by DSS workers to prevent pages missing, dates not matching, etc.