VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Emily Green Shores
500 Westmoreland Avenue
Portsmouth, VA 23707
(757) 399-3442

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: June 3, 2020 , June 5, 2020 and June 8, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 06-03-2020 and concluded on 06-08-2020. A complaint was received by the department regarding allegations in the areas of Administration and Administrative Services and Resident Care and Related Services. 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 did not support the allegations of non-compliance with standards or law.

Violations:

Standard #:	22VAC40-73-325-C
Complaint related:	No
Description:	Based on resident records reviewed and interview, the facility failed to document interventions that were initiated to prevent or reduce risk of subsequent falls when a resident who meets the criteria for assisted living care falls. Evidence: 1. Resident #2?s current Uniform Assessment Instrument dated 06-13-2019 documented the resident meets criteria for assisted living care. 2. The ?Nurses Notes? documented resident #2 had a fall on 04-13-2020 and 05-05-2020. A fall risk rating was completed for resident #2?s falls on 04-13-2020 and 05-05-2020; however, the rating did not include interventions that were initiated to prevent or reduce risk of subsequent falls. 3. Resident #2?s current Individualized Service Plan (ISP) documented the resident is a fall risk and the fall interventions were last updated on 04-10-2020; however, the ISP was not updated to include interventions to prevent or reduce risk of subsequent falls per resident?s falls on 04-13-2020 and 05-05-2020. 4. Staff #1 could not provide documentation of interventions that were initiated after each of resident #2?s aforementioned falls. 5. Staff #1 acknowledged the facility did not document fall risk interventions for resident #2?s aforementioned falls.
Plan of Correction:	RCC will implement and document the intervention plan to prevent or reduce the risk of subsequent falls for each resident fall at time of incident. If third party intervention is ordered by the physician the plan will be added to the ISP for staff review and implementation.