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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: Dec. 9, 2020

Complaint Related: Yes

Areas Reviewed:
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 alternative remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia.

The evidence gathered during the investigation did not support the allegation. Any violations not related to the complaint and identified during the course of the investigation can be found on the violation notice.

Violations:
Standard #: 22VAC40-73-330-C
Complaint related: Yes
Description: Based on document review and staff interview, the facility failed to ensure a mental health screening by a qualified mental health profession having no financial interest in the assisted living facility, directly or indirectly as an owner, officer, employee, or as an independent contractor with the facility was conducted.

Evidence:
1. During a complaint inspection regarding the resident not receiving medications, a review of resident #1's uniformed assessment instrument and interview with staff #1 revealed the resident's admission to a private hospital for behaviors that were indicative of mental illness within six months prior to resident #1's admission to the assisted living facility Further interview revealed resident #1's discharge was directly to the facility from the hospital's psychiatric unit.
2. Interview with staff #1,revealed the facility did not have of a documentation a mental health screening by a qualified mental health professional prior to admission. Resident #1's record also did not include documentation of the reason for delay of the mental health screening.

Plan of Correction: We now have a procedure included in the admission packet to ensure all required documents are complete, including the mental health assessment, prior to admission.

Standard #: 22VAC40-73-340-C
Complaint related: Yes
Description: Based on record review and staff interview, the facility failed to ensure if an individual is admitted, the psychosocial and behavioral history shall be used in the development of the resident's individualized service plan (ISP).

Evidence:
1. During the complaint inspection regarding resident not receiving medication, a review of resident #1's record and interview with staff #1, the resident's individualized service plan (ISP) dated 7-14-20 was conducted. The ISP did not include documentation of the resident's psychosocial and behavioral information.
2. Further review of the resident's clinical information to the facility faxed to the facility on 7-9-20 documented resident #1's mental health status upon admission to the hospital: "psychotic disorder due to Parkinson's disease with hallucinations, unspecified depression.
3. Further review of resident #1's physician's orders dated 7-30-20 following discharge to the facility noted medications to address residents mood disorder and major depressive disorder (Wellbutrin, Seroquel, and Zoloft).

Plan of Correction: All information relevant to resident care, including psycho-social & behavioral issues will be included on the ISP.

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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