VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Golden Years Assisted Living Facility, Inc.
40 Hunt Club Boulevard
Hampton, VA 23666
(757) 825-2425

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: Sept. 22, 2020 , Oct. 1, 2020 and Oct. 7, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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 09/22/2020 and concluded on 10/07/2020. A complaint incident was received by the department regarding allegations in the areas of 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES and 22VAC40-73-(2) ADMINISTRATION AND ADMINISTRATIVE 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 supported the allegation(s) of non-compliance with standards or law, and violations were issued. Any violations not related to the (complaint(s)/self-report) but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-40-A
Complaint related:	No
Description:	Based on staff interviews and record review, the licensee failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state, and local laws; with other relevant regulations; and with the facility's own policies and procedures. Evidence #1: On 10/07/2020 while reviewing the facility policy, "Resident Medication Orders" reads, "All medication orders, prescription and non-prescription medications shall...b) Be obtained upon admission, when orders change and every three months thereafter". Evidence #2: While reviewing resident #1's medication administration record (MAR) for the month of March, 2020 the (MAR) reads,"suspended 09 Mar 2020 to 10 Mar 2020: hospital".Upon resident #1's return from the hospital, the (MAR) reflected multiple medications discountinued. The Licensing Inspector requested discontinue orders provided by resident #1's physician. Based on statements provided by staff #1, #2 and #3 and of the last day of the inspectyion the facility did not request nor obtain physician orders for any medications discontinued between 03/10/2020 and 03/19/2020.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on resident record review the facility failed to ensure medications shall be administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: On 10/07/2020 while reviewing the medication administration record (MAR) for resident #1, the record evidences 10 out of 21 prescribed medications were not administered between March 10th, 2020- March 19th, 2020. Based on staff interviews provided by staff #1, #2 and #3, the facility did not have discontinue orders for the following medications that were reflected on the medication administration record as/or discontinued and not administered: Asprin Chew 81mg- take 1 tablet by mouth once daily, Clonazepam Tablet 0.5mg- take one tablet by mouth twice daily, Clonazepam Tablet 0.5mg -take 2 tablets=1mg by mouth every night at bed time, Clozapine tablet 100mg-take 2 tablets=200mg by mouth twice daily, Fiberlax 625mg-take 1 tablet by mouth once daily, Lidocain Oin 5%-apply 3 times a day to affected areas for pain, Morphine Sulfate 15mg ER-take 1 tablet by mouth every 12 hours, Tamoxifen tablet 20mg- take 1 tablet by mouth daily.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on resident record review the facility failed to ensure the medication administration record included diagnosis, condition, or specific indications for administering the drug or supplement. Evidence#1: On 10/07/2020 during review of the medication administration record (MAR) for resident #1, the (MAR) did not contain the diagnosis, condition, or specific indications for administering the drug or supplement for all medications administered during the months of February, March, April, May, June or July, 2020.
Plan of Correction:	Not available online. Contact Inspector for more information.