VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Town Creek Assisted Living Facility
393 Front Street
Lovingston, VA 22949
(434) 263-4313

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: July 9, 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 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

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 renewal inspection was initiated on 7/9/2020 and concluded on 7/10/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 47. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, staff schedules, Fire and Health inspections, health care oversights, fire drill logs and dietitian reports submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records, the facility failed to ensure that all staff received certification in first aid within 60 days of employment. EVIDENCE: !. the record for staff person 3, employed on 9/3/2019, did not have documentation of the employee being certified in first aid within 60 days from the date of employment.
Plan of Correction:	The Administrator will contact local entities to schedule a first aid class for the this staff person. The Administrator or designee will preform routine audits on new staff records to ensure that first aid certification is completed within the required time frame.
Standard #:	22VAC40-73-320-A
Description:	Based on a review of resident records, the facility failed to ensure that physical examinations were completed as required. EVIDENCE: 1. The physical examination in the record for resident 2, admitted on 11/18/19, does not have a date that the examination was completed. 2. The physical examination dated 7/11/19 in the record for resident 3, admitted on on 7/16/19, is incomplete as it lacks documentation as to whether the resident can or can not self administer medication.
Plan of Correction:	The Administrator or designee will contact the residents physicians to have them complete the physical examination forms. The administrator or designee will conduct audits of new resident records to ensure that physical examinations are completed at the time of admission.
Standard #:	22VAC40-73-325-B
Description:	Based on a review of resident records, the facility failed to ensure that a fall risk rating was completed after a resident sustained a fall. EVIDENCE: 1. The record for resident 1 has documentation in nursing notes of the resident falling on 6/10/20. The record did not contain documentation of a fall risk rating being completed for this fall.
Plan of Correction:	The Administrator or designee will conduct a fall risk rating to evaluate the circumstances of the residents previous fall. The Administrator will develop a system to identify when a resident has fallen to ensure that a fall risk rating is completed at that time.
Standard #:	22VAC40-73-440-E
Description:	Based on a review of resident records, the facility failed to ensure that public pay unifrom assessment instruments (UAIs) were completed as required. EVIDENCE: 1. The UAI dated 4/29/2020 in the reord for resident 1 is incomplete as it lacks documentation of the residents needs for dressing. Also the UAI is inconsistent as it has the resident requires mechanical assistance with bathing. The individualized service plan (ISP) dated 5/13/2020 for resident 1 has that the resident requires assistance. A phone interview with staff person 4 expressed that resident 1 does require staff assistance with bathing. 2. The UAI dated 6/20/20 in the record for resident 3 has documentation that the resident is independent with bathing and has appropriate behaviors. The ISP dated 7/16/19 has that the resident requires staff supervision for this ADL need. A phone interview with staff person 2 expressed that the UAI is incorrect and the resident does require supervision with bathing and has a history of agitation/ behaviors.
Plan of Correction:	The Administrator will contact the public pay assessors to make them aware of the changes needed on the residents UAI's. The Administrator or designee will ensure coordination with assessors to ensure UAI's reflect accurate ADL needs.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The record for resident 2 has documentation on a fall risk rating form dated 11/18/19 that the resident is a risk for falls. The ISP dated 11/18/19 does not address this identified need. 2. The record for resident 3 has documentation on a fall risk rating form dated 7/16/29 that the resident is a risk for falls. Also the record has documentation in nursing notes of the resident displaying agitated behavior on 5/6/20 ans 5/31/20, Physician orders dated 6/2/20 have a No Concentrated Sweet diet list for the resident. The ISP dated 7/16/19 does not address these identified needs.
Plan of Correction:	The Administrator or designee will update the residents ISP's to reflect there current assessed needs. The Administrator of designee will conduct routine audits to ensure accuracy of resident ISP's.
Standard #:	22VAC40-90-40-B
Description:	Based on a review of staff records, the facility failed to ensure that a criminal history record report was obtained on or prior to the 30th day of work for all employees. EVIDENCE: 1. The record for staff person 5, hired on 9/9/2019 did not contain the results of a criminal history record report as of the day of inspection. Per a phone interview with staff person 4, the results were not completed as the staff person finger prints were to light.
Plan of Correction:	The Administrator will contact human resources to obtain a criminal history report for this staff person. The Administrator has discussed making revisions to the facility policies for obtaining criminal reports for new staff and will ensure that all new staff have a criminal record report within 30 days from the date of employment.
Standard #:	22VAC40-90-60-A
Description:	Based on a review of staff records, the facility failed to ensure that original crimnal history reports were maintained at the facility where the person is employed. EVIDENCE: 1. The record for staff person 6, hired on 9/9/2019 has documentation on a corporate generated form that the staff person has a criminal record and that the original criminal history record report has been destroyed. The LI was not able to review the original the original report on the day of inspection.
Plan of Correction:	The Administrator will contact human resources to obtain a criminal history report for this staff person. The Administrator has discussed making revisions to the facility policies for obtaining and maintaining criminal reports for new staff in their record at the facility.