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Cary Adult Home
7336 Cary Avenue
Gloucester, VA 23061
(804) 693-7035

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: June 8, 2020

Complaint Related: No

Areas Reviewed:
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
22VAC40-73 PERSONNEL
22VAC40-73 STAFFING AND SUPERVISION
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
22VAC40-73 EMERGENCY PREPAREDNESS

Comments:
This inspection was conducted by the licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia.
A self-report complaint inspection was initiated on 5-12-20 and concluded on 6-1-20. A self-reported incident was received by the department regarding the unexpected death of a resident. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation.
The evidence gathered during the investigation support the self-report of non-compliance with standards, or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:
Standard #: 22VAC40-73-280-D
Description: Based on interview the facility failed to ensure staff had adequate knowledge, skills and abilities to provide services to maintain physical well-being of a resident.

Evidence:
1. During the remote self-report complaint inspection, staff #3, #4 and #5 stated not knowing what to the protocol in the facility was when a resident did not return or was not in the facility during sleeping hours.
2. Staff stated not having knowledge of the missing person or elopement procedures for the facility or participating in resident emergency exercises. Document submitted by the facility noted training conducted March 2020, however, there were no staff signatures on the resident emergency training document submitted on 5-20-20. Documents also submitted not "staff meeting" with statement regarding emergency procedures, however, the document did not note resident emergency procedures.
3. Staff #5 stated being new and worked as the cook and work overnight a few times. Staff stated not having assisted living or direct care training prior to being hired 3-3-20.
4. Staff #4 stated residents are free to come and go, and staff #3 was the lead staff on evening of March 31, 2020. Staff #3 (date of hire 6-18-18) and #4 (date of hire 9-27-19) not aware of facility requirement regarding resident's schedule and activities and what to do when resident is missing or not in building. Staff not aware of when rounds should be conducted in facility.

Plan of Correction: The staff has been re-trained, and Policies and Procedures have been discussed, and all staff are aware of their duties when a resident situation may occur. Also the designated staff person in charge has been given their specific duties as it relates to supervision in the facility, when the administrator is not in the facility.

Corrected May 14th and May 29th, 2020

Standard #: 22VAC40-73-460-D
Description: Based on record review and staff interview, the facility failed to ensure it provide supervision of resident schedules, care and activities including attention to specialized need such as wandering from the premises.

Evidence:
1. On 4-1-2020, a self-reported incident was reported to the office of licensing by staff #1. Staff #1 left a voice message informing of resident #1's being found face down on the ground on the path in the woods behind the facility, resident transported to the hospital following 911 call. According to staff #1, the resident had expired, cause of death not known.
2.According to staff #1, resident #2 reported to staff #1 and staff #3 that resident #1 was on the path in the woods. LI interview with resident #2 and review of resident's written statement confirmed resident #1 being found face down on the ground in the woods on the morning of April 1, 2020. Resident #2's statement and interview stated touching the resident and the resident not moving.
3. An interview with staff #2 and staff's written statement confirmed resident #1's being found face down off the pathway in the woods behind the facility. Staff stated resident was not in the facility upon staff's arrival for the 11pm- 7am shift on March 1, 2020/April 1, 2020.
4. Staff #1 stated the path was used by residents to go to local establishment on US. Route 17 (George Washington Highway). Staff #1 also stated resident #1 had made a shelter area of the path out of various items where resident would often retreat. Staff stated resident was not one to leave the facility. The area in the woods was a place for privacy but never did the resident not return daily to the facility.
5. The inspector inquired of staff what the weather was on the night of March 31, 2020 and morning of April 1, 2020 when resident #1 was found outside. Staff #1 stated it had rained during the night.Interview with staff #2, staff stated the weather was cold on the night of March 31, 2020/ morning of April 1, 2020.Staff #2 also noted in statement and during interview, being asked by 911 operator to grab a blanket to cover resident #1 until medics arrived.
6. A check of Accu weather noted the temperature on the night of March 1, 2020 was noted as: High 54 degrees/low 44 degrees. The temperature for the morning of April 1, 2020 was noted as: High 51 degrees/low 44 degrees.
7. Staff #3 stated resident did not come into the facility to receive evening medications on 3-11pm shift and was not present in the facility when staff left facility. A review of resident's March 2020 medication administration record (mar) noted resident's medication dosage time is 8:00pm. A review of the mar noted signed by staff #3, at 10:17pm noted resident "out of facility". Staff #3 stated informing oncoming staff (11pm- 7am) of resident not receiving medication and not being in the building.
8. According to staff #1, no staff on either shift contacted the administrator to inform that resident #1 was not in the facility.

Plan of Correction: The resident schedules, care and activities have been discussed, at length, with all staff. The situation about the resident and what transpired has been discussed. A training on Policies and Procedures has been completed and all staff have signed they know what to do in the event a missing resident occurs.

Corrected May 14th and May 29th, 2020

Disclaimer:
A compliance history is in no way a rating for a facility++.

The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.

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