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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: Nov. 2, 2020 , Nov. 4, 2020 , Nov. 10, 2020 and Dec. 10, 2020

Complaint Related: No

Areas Reviewed:
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 BUILDING AND GROUNDS
22VAC40-73 EMERGENCY PREPAREDNESS
32.1 Reported by persons other than physicians
22VAC40-90 Background Checks for Assisted Living Facilities
22VAC40-90 The Sworn Statement or Affirmation
22VAC40-90 The Criminal History Record Report

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 monitoring inspection was initiated on 11-2-20 and 11-4-20 and concluded on 12-10-20. The administrator was contacted by telephone to initiate the inspection. The administrator reported the current census of 56. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four resident records, 4 staff records, staff written schedule, fire and emergency drills, healthcare oversight, pharmacy review, health and fire inspections submitted by the facility to ensure documentation was complete.
Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:
Standard #: 22VAC40-73-120-B
Description: Based on record review and staff interview, the facility failed to ensure staff orientation included all required orientation information for two of four record.

Evidence:
1. During the remote monitoring inspection, a review of staff #4's orientation document signed and dated by staff 3-27-30, did not include orientation to the facility's organizational structure.
2. Further review of staff #5's orientation document signed and dated by staff on 9-11-20 did not include orientation to the facility's organizational structure.

Plan of Correction: Will update orientation document for new hires with new required items.

Standard #: 22VAC40-73-200-C
Description: Based on record review, the facility failed to ensure staff met one of the requirements per the regulation for employment as a direct care staff.

1. During the remote monitoring inspection a review of staff #4's orientation document indicated staff as a direct care staff (dcs)- cook. A review of the staff information sheet provided by the facility indicated staff #4 position as care aide. However, a review of documents provided did not include a copy of the requested certificate/credential indicating staff #4's direct care training.

Plan of Correction: Will ensure all employees have proper documented training for assigned title.

Standard #: 22VAC40-73-210-F
Description: Based on record review, the facility failed to ensure when adults with mental impairments reside in the facility, at least four of the required hours shall focus on topics related to residents' mental impairments for two of four record.

Evidence:
1. During the remote monitoring inspection, a review of staff #3's training record indicated staff completed three of the required four hours of annual mental impairment training. Staff #3's date of hire noted as 9-1-19.
2. Further review of staff #6's training record did not include documentation of mental impairment training. Staff #6's date of hire noted as 9-20-19.

Plan of Correction: Will ensure all employees have required training documented in training record on employee file.

Standard #: 22VAC40-73-260-A
Description: Based on record review, the facility failed to ensure direct care staff member shall receive certification in first aid within 60 days of employment.

Evidence:
1. During the remote monitoring, a review of staff #4's first aid document indicated first aid completed on 8-26-20. A review of the staff information sheet provided indicated staff's date of hire was 3-30-20.

Plan of Correction: Will continue to ensure all employees First Aid training is up to date as state of emergency restrictions allow.

Standard #: 22VAC40-73-290-A
Description: Based on document review, the facility failed to ensure the written work scheduled maintained included all required information.

Evidence:
1. During the remote monitoring inspection, a review of the facility's written work schedule submitted on 11-9-20 and 12-10-20 did not include the names and job classification of all staff working each shift. The list indicated the initials of staff members. Further review revealed, the document did not include the job classification of the staff.

Plan of Correction: Will maintain current three page schedule with all staff's names, job titles, and initials and update as new employees are hired.

Standard #: 22VAC40-73-310-H
Description: Based on record review, the facility failed to ensure it did not admit or retain individuals with any of the prohibitive conditions per the regulations without required documents. Four of four residents record reviewed noted psychotropic medications without a treatment plan.

Evidence:
1. During the remote monitoring inspection, a review of resident #1's October 2020 medication administration record (mar) noted the following psychotropic medications: (a) Divalproex (Depakote) and Sertraline (Zoloft), however, no treatment plan was provided during the inspection..
2. A review of resident #2's October 2020 medication administration record (mar) noted Buspirone (Buspar) Divalproex (Depakote) and Mirtazapine (Remeron). However, no treatment plan was provided during the inspection
3. A review of resident #3's October 2020 medication administration record (mar) noted Fluoxetine (Prozac), Fluphenazine (Prolixin Deconate), Hydroxyzine PAM (Vestaril) and Quetiapine Fumerate (Seroquel).
4. A review of resident #4's October 2020 medication administration record (mar) noted Aripiprazole (Abilify), Lorazepam (Ativan) and Olanzapine (Zyprexa). However, no treatment plan was provided during the inspection.
5. The request for treatment plans for psychotropic medications noted were not provided. Staff #1, stated documents not available for the four residents' records reviewed during the inspection.

Plan of Correction: Will ensure all residents who are prescribed psychotropic medications will have a completed treatment plan signed by psychiatric provider on their chart.

Standard #: 22VAC40-73-450-C
Description: Based on record review, the facility failed to ensure the individualized service plan (ISP) contained all assessed needs for three of four residents.

Evidence:
1. During the remote monitoring inspection, a review of resident #2's physical examination dated 8-5-20 noted the resident is allergic to Bee-venom and Iodine. A review of the uniformed assessment instrument (uai) dated 7-24-20 assessed resident need for mental health services. These noted information were not documented on the individualized service plan (ISP) dated 9-10-20.
2. A review of resident #3's uai dated 8-26-20 assessed resident's need for mental health services, wandering and short-term memory loss. These noted information were not documented on the ISP dated 10-29-20.
3. A review of resident #4's uai dated 12-19-19 assessed resident's as disoriented some spheres some time. This need was not noted on the ISP dated and signed 12-19-20.

Plan of Correction: Will ensure UAI needs and ISP services match for all residents and are updated as needed.

Standard #: 22VAC40-73-450-F
Description: Based on record review, the facility failed to ensure the individualized service plan is updated as needed as the condition of the resident changes. The review and update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons.

Evidence:
1. During the remote monitoring inspection a review or resident #1's uniformed assessment instrument (uai) dated 8-10-20 and completed by case manager assessed need for mechanical help with stairclimbing. Assessed need not documented on individualized service plan (ISP) dated 6-10-20. The ISP was not updated to reflect change.
2. Further review of the uai dated 8-10-20 assessed resident #1 as independent with bathing, dressing, toileting and transferring. However, a review of the ISP dated 6-10-20 noted," bathing, dressing, toileting, transferring mechanical assistance need date 05/21/2019". and services to be provided, "c/r will have access to equipment needed to perform ADLs". ISP not updated to reflect recent assessed change of need for resident #1.



.

Plan of Correction: Will ensure UAI needs and ISP services match for all residents and are updated as needed.

Standard #: 22VAC40-73-470-A
Description: Based on record review, the facility failed to ensure, either directly or indirectly, that the health care service needs of one of four resident was met.
Evidence:
1. During the remote monitoring inspection, a review of resident #3's admission's physical examination dated 8-31-20 noted need for physical therapy services. Further review of resident's record and individual service plan (ISP) dated 10-29-20 did not include documentation of services completed with an achieve date or services being provided by a homehealth agency with a start of care date.

Plan of Correction: Will continue to schedule therapy when ordered. Will also continue to discuss recommendations received with resident and/or representative and doctor, and get a written order from doctor in order to schedule appropriate therapies needed.

Standard #: 22VAC40-73-650-A
Description: Based on record review, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber.

Evidence:
1. During remote monitoring inspection, a review of resident #1's October 2020 medication administration record (mar) indicated Cephalexin (Keflex) 500 mg for 10 days, start date 10-7-20 and end 10-17-20 and Cephalexin 500 mg, start date 10-18-20 and end date 10-28-20. Levofloxacin (Levaquin) start date 10-7-20 and end date 10-17-20 and 10-18-20 start and 10-28-20 end date. . Review of physician's order submitted dated 9-3-20 did not include orders to start the aforementioned medications. Further review of resident #1's mar noted the following medications were noted "dc'd" (Hydrocodone-Acetaminophen 10-325mg, Tramadol HCL 50 mg and Hydrocodone-APAP 5/325mg. However, a review of physician's orders submitted dated 9-3-20 did not include stop orders.
2. Resident #2's October 2020 mar noted "dc'd" for Nystatin100k powder, however, the physician orders submitted dated 10-1-20 did not include stop order.
3. Resident #3's October 2020 mar noted "dc'd" for Methocarbamol 500mg and Oxycodone-APAP5-325mg. However, physicians orders submitted dated 10-1-20 did not include order to start medications.
4. Resident's medications were started or discontinued (dc'd) without physician's orders. Physicians orders requested for all medications noted on the October 2020 mars.

Plan of Correction: Will continue to follow doctor's orders to administer medications for specific time period indicated on prescription, Will continue to stop administration of medication after doctor has prescribed medication to end. Will continue to consider written prescription from doctor as order to start medication.

Standard #: 22VAC40-73-650-B
Description: Based on record review, the facility failed to ensure the physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug.

Evidence:
1. During the remote monitoring inspection, a review of resident #1's physician order dated, 9-3-20, for Vitamin D2 1.25mg did not include the route.
2. Further review of resident #2's physician's order dated 10-1-20, the handwritten orders for Trazadone and Vistaril did not include the diagnosis, condition, or specific indications for administering each drug.

Plan of Correction: Will request all doctors include drug strength, dosage, route, frequency, and diagnosis on all prescriptions.

Standard #: 22VAC40-73-680-D
Description: Based on 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 for one of four residents.

Evidence:
1. During the remote monitoring inspection, a review of resident #3's October 2020 medication administration record (mar), noted resident's Basaglar 100 unit/ml (Lantus Solostar) was to be administered every evening. Further review of the mar revealed medication was administered by staff at 8:00 am. A review of the physician's order dated 10-2-20 noted resident was to receive the medication every evening. Resident's medication not administered according to the
evening time indicated by the prescriber.

Plan of Correction: Will monitor pharmacy entries for prescription times to match written physician order.

Standard #: 22VAC40-73-680-I
Description: Based on record review, the facility failed to ensure the medication administration record (mar) included all required information for one of four resident.

Evidence:
1. During the remote monitoring inspection, a review of resident #2's October 2020 medication administration record (mar), the diagnosis, condition, or specific indications for administering the drug or supplement was not noted for the following: Docusate sodium (Colace), Fish OIl, Furosemide (Lasix), Isosorbide (Imdur), Meloxicam (Mobic), Omeprazole (Prilosec) and Oxybutynin (Ditropan).

Plan of Correction: Will ensure all MARs contain information regarding diagnosis and/or indications for use/administration for each medication.

Standard #: 22VAC40-73-680-K
Description: Based on record review, the facility failed to ensure the administration of PRNs included the exact dosages and exact time and what to do if symptoms persist.

Evidence:
1. During the remote monitoring inspection, a review of resident #1's October 2020 medication administration record (mar) and physician's order dated 9-3-20, noted Dakins 0.125 solution use for wound care: "changes every 2-3 days". Further review of the mar noted, Diphenhydramine 25 mg administer "every six to eight hours as needed". Lidocane HCL 4% solution, "apply 5 to 10 ml to gauze..."
2. Medications and treatments noted ranges and not exact dosages and or time.

Plan of Correction: Will request all doctors not include ranges for dosages, frequencies, or quantities of medications on written prescriptions.

Standard #: 22VAC40-73-940-A
Description: Based on document review, the facility failed to ensure it comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official.

Evidence:
1. During the remote monitoring inspection conducted on 11-4-20, a review of the fire inspection submitted on 11-9-20 revealed the date of the facility's last inspection was dated 10-8-19.
2. According to staff #1 and #2, an annual inspection had not been completed.

Plan of Correction: Will continue to have fire inspections annually as state of emergency restrictions allow."

Standard #: 22VAC40-90-40-B
Description: Based on record review, the facility failed to ensure the criminal history record was obtained on or prior to the 30th day of employment for a staff.

Evidence:
1. During a review of new hire records, staff #9's criminal history report was dated 10-29-20. A review of the list of new hire date document and staff information document submitted by the facility indicated staff #9's date of hire 9-12-20. The staff's criminal report was more than 30 days from date of employment.

Plan of Correction: Will ensure re-hires have a new background check completed within 30 days of re-employment.

Standard #: 22VAC40-90-40-C
Description: Based on record review, the facility failed to ensure it did not employ a person who was ineligible for employment if the criminal history record report contain convictions of the barrier crimes.

Evidence:
1. During the remote monitoring inspection, a review of the criminal history reports submitted for new hires was conducted. Further review of staff #8's criminal history report dated 10-21-20 contained barrier crimes which made staff ineligible for employment in an assisted living facility. Staff's criminal history report received by inspector on 11-9-20 and staff's date of hire noted on the staff information document as 10-19-20.

Plan of Correction: Will continue to perform background checks on new hire employees. Those with convictions of barrier crimes will not be employed. Those with charges of barrier crimes will be evaluated on a case-by-case basis depending on nature of, number of, and length of time since charges.

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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