VIRGINIA DEPARTMENT OF SOCIAL SERVICES

LAV'M Adult Residence
912 S. Battlefield Blvd.
Chesapeake, VA 23322
(757) 546-2810

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: March 5, 2020

Complaint Related: No

Areas Reviewed:

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:

An unannounced renewal inspection was conducted from 8:28 a.m. until 2:21 p.m with co-worker N.P. The cook/direct care staff , the administrator, and two other direct care staff were present. There were 21 residents in care. Six resident records and four staff records were reviewed. Medication administration was observed and interviews were conducted. The lunch meal of fish patty , macaroni salad, lettuce salad , peaches ,and broccoli was observed . There was discussion about breakfast meats and breakfast foods served. Also there was discussion about the availability of snacks. The resident council started two months ago . The minutes did not reflect any resident concerns . The facility was encouraged to keep the residents engaged in fun, interactive, stimulating activities. The call bells were checked in all the resident room . Staff were reminded not to silence the alarms . Please complete the ?plan of correction? for each violation cited on the violation notice and return it to me within 10 calendar days from today on 4-20-20 You will need to specify how the violation will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must include: 1. steps to correct the noncompliance 2. measures to prevent reoccurrences 3. Person(s) responsible for implementing and monitoring each step of the corrective measures and / or the preventative measures.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on two out of four staff records reviewed and an interview, the facility failed to ensure the staff had a tuberculosis (TB) evaluation annually and submitted the results of a risk assessment, documenting that the individual was free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. Staff #3's last TB risk assessment was dated 07-07-2018 and staff #4's last TB risk assessment was dated 09-27-2018. Staff #1 could not locate or provide documentation of a current annual TB risk assessment on file for staff #3 or staff #4. 2. Staff #1 acknowledged the staff did not have a current annual TB evaluation.
Plan of Correction:	Licensee and Administrator assures that medications with specific times and instructions will be administered in accordance with the Physician?s orders. The Facility will fax new orders to the pharmacy as soon as physician orders are received, and will make necessary changes therewith.
Standard #:	22VAC40-73-260-A
Description:	Based on one of four direct care staff records reviewed and an interview, the facility failed to ensure staff maintained a current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Resident #4?s first aid certification expired on 02-05-2020. Staff #1 could not locate or provide a copy of staff #4?s current first aid certification. 2. Staff #1 confirmed staff #4?s first aid certification was expired.
Plan of Correction:	The Licensee and Administrator are scheduling staff #4?s First Aid Certification Renewal.
Standard #:	22VAC40-73-490-A-2
Description:	Based on record review and interview, the facility failed to retain a licensed health care professional. The licensed health care professional, practicing within the scope of his/her profession, should provide health care oversight at least every six months. Evidence: 1. When asked for a copy of the facility?s healthcare oversight, staff #1 stated she was ?looking for a nurse to complete the health care oversight.? 2. Staff #1 provided the last documented healthcare oversight on file which was dated 11- 29-2018. 3. As of 03-05-20, the facility had not retained a licensed health care professional and did not have a health care oversight completed every six months as required.
Plan of Correction:	The Licensee and Administrator had secured a licensed professional to do health care oversight every quarter. This has commenced two days after the State Inspection. Oversight Nurse has completed her duty and charting was dated March 7, 2020.
Standard #:	22VAC40-73-550-G
Description:	Based on four staff records reviewed and an interview, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities are reviewed annually. Evidence of this review should be the staff person's written acknowledgment of having been so informed, which should include the date of the review and should be filed in the staff person's record. Evidence: 1. The most current residents rights review for staff #1 was dated 02-01-2018, staff #2 and #3 was dated 10-18-2018, and staff #4?s was dated 11-01-2018. None of the staff had written acknowledgment of a current annual review of the rights and responsibilities of residents in assisted living facilities. 2. Staff #1 confirmed the staff did not have a current annual review of the resident?s rights and responsibilities.
Plan of Correction:	The Licensee and Administrator assures that ALL Staff will review the Residents? Rights and Responsibilities, acknowledge, and sign the documents. Licensee and Administrator assures further that these documents will be filed in the staff person?s record.
Standard #:	22VAC40-73-680-B
Description:	Based on observation, record review, and interview, the facility failed to ensure all medications administered by the registered medication aide, remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. Evidence: 1. Upon arrival to the facility at approximately 8:28 a.m., staff #2 stated that all morning medications had been administered. 2. At approximately 9:05 a.m., resident #8 entered the dining area and sat at the table across from the medication cart. While standing next to the medication cart with staff #1, staff #2 was observed unlocking the medication cart; and took out a pill cup which contained three pills. The pills were not in the pharmacy issued container with the prescription label or direction label attached. 3. When asked about the pills, staff #2 stated "these are resident #8's pills." Staff #2 identified the pills as Vitamin D-3, Divalproex Acid 250mg, and Actos 30mg. 4. Staff #1 and #2 acknowledged resident #8?s pills did not remain in the pharmacy issued container, with the prescription label or direction label attached, until administered.
Plan of Correction:	Licensee and Administrator assures that all medications are to be administered to the residents will remain in the pharmacy issued container with the prescription label or direction label attached until administered. In addition, licensee and administrator will provide in service and refresher course to the medication aid.
Standard #:	22VAC40-73-680-C
Description:	Based on observation, record review, and an interview the facility failed to ensure all medications were administered as ordered for specific times, such as before, after, or with meals. Evidence: 1. At approximately 12:15 p.m. staff #2 was observed administering Sinemet 25/100mg to resident #7; while the resident was eating lunch. 2. Resident #7?s signed physician?s order dated 02-26-2020, documented for Sinemet 25/100mg to be administered 30 minutes before eating, and not during lunch as was observed. 3. During interview staff #1 and staff #2 acknowledged resident #7?s Sinemet 25/100mg was not administered at a specific time before meals as ordered.
Plan of Correction:	Licensee and Administrator assures that medications with specific times as ordered by the physician will be strictly followed. Medication aid will be reviewed from time to time in administering medications.
Standard #:	22VAC40-73-680-D
Description:	Based on observation, record review, and an interview the facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. Evidence: 1. At approximately 12:03 PM, staff #2 was observed administering Tylenol ES500mg to resident #4. 2. Resident #4?s signed physician?s order dated 02-20-2020, documented for the Tylenol ES500 to be administered every 8 hours; however, the March 2020 Medication Administration Record (MAR) documented the Tylenol ES500 is scheduled to be administered at 8:00 a.m., 1:00 p.m., and 12:00 a.m.; which is not every 8 hours per the physician?s instructions. 3. At approximately 12:20 p.m., staff #2 was observed administering Apresoline 25mg to resident #3. 4. Resident #3?s signed physician?s order dated 02-03-2020, documented for the Apresoline 25mg tablet to be administered every 8 hours, however, the March 2020 MAR documented the Apresoline 25mg tablet is scheduled to be administered at 6:00 a.m.; 1:00 p.m.; and 9:00 p.m.; which is not every 8 hours per the physician?s instructions. 5. When asked what time the morning dose of Apresoline 25mg was administered to resident #3, staff #2 stated he had "given the morning dose around 8:00 a.m.". 6. Staff #2 acknowledged resident #3?s Apresoline 25mg and resident #4?s Tylenol ES500 was not administered in accordance with the physician?s instructions.
Plan of Correction:	Licensee and Administrator assures that medications with specific times and instructions will be administered in accordance with the Physician?s orders. The Facility will fax new orders to the pharmacy as soon as physician orders are received, and will make necessary changes therewith.