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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: Feb. 10, 2021 , Feb. 17, 2021 and Feb. 23, 2021

Complaint Related: Yes

Areas Reviewed:
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 EMERGENCY PREPAREDNESS

Comments:
The 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 2-10-21. A complaint was received by the department regarding allegations in the resident and related areas, admission and incident reporting areas of the standard. 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 allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaints but identified during the course of the investigation can be found on the violation notice.

Violations:
Standard #: 22VAC40-73-450-C
Complaint related: Yes
Description: Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) included all assessed needs.

Evidence:
1. Resident #1's uniformed assessment instrument dated 8-18-20 documented, resident as a wanderer and required supervision for wandering behavior. The individual service plan (ISP) dated 10-1-20 did not include resident's wandering behavior/need for supervision. Resident wandered from the facility on the night of 10-17-20 and was returned by the sheriff's office. Resident also wandered from the facility on the afternoon of 12-3-20 and did not return.
2. Interview with Staff #2, the developer of resident #1's ISP, was aware of the resident leaving the facility on the night of 10-17-20. However, the ISP was not updated to reflect the resident's wandering/ behavior need. Staff #2 was not aware of the resident's wandering need identified on the UAI.
3. Staff #1 and #2 acknowledged, wandering need was not addressed on resident's ISP.

Plan of Correction: On 12/3/2020, based on video evidence, resident #1 walked outside. It is any residents' right to be able to go outside the facility. We are residential and are not allowed to lock our doors to prevent residents from leaving. Once it was determined resident #1 had missed the evening meal, the local authorities and legal guardian were notified. Administrator and/or designee will review ISPs monthly to ensure any additional observations/needs identified are addressed.

Standard #: 22VAC40-73-470-A
Complaint related: No
Description: Based on record review and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of a resident was met.

Evidence:
1. Resident #1's admission physical and examination signed and dated 8-28-20, the physician documented resident need for therapy services, "psychotherapy/counseling".
2. Interview with staff #1, resident did not see anyone for psychotherapy or counseling services. According to staff, the facility had a mental health personnel who visited the facility and monitored the resident?s psychotropic medications. When asked if resident was receiving the therapy services addressed on the physical examination, staff #1 was not aware of the need documented on the resident's admission physical.
3. Staff #1 acknowledged resident #1 was not receiving psychotherapy/counseling therapy services.

Plan of Correction: Resident #1 did receive psycho-therapy/counseling services, provided by the PACT team and physician, through the Community Services Board. Dates Services were provides: documented w/ PACT/CSB.
Administrator and/ or designee will continue to monitor physicals and UAIs for psychotherapy/counseling therapy services to ensure those services are provided.

Standard #: 22VAC40-73-640-A
Complaint related: Yes
Description: Based on record review, the facility failed to ensure the facility's medication management plan was followed to ensure resident's prescription medications ordered is filled and refilled in a timely manner to avoid missed dosages.

Evidence:
1. Resident #1's October 2020 medication administration record (MAR) documented resident's Junel FE medication, prescribed daily for 28 days, was not available to administer on the following dates: 10-5-20; 10-13-20; 10-15-thru 10-17-20; 10-20-20; 10-22 thru 10-25-20 and 10-30-20. Medication staff members documented on resident's MAR, medication pending prescription from physician.
2. Resident's November 2020 MAR also documented Junel FE medication, not available to administer on the following dates: 11-9-20; 11-10-20; 11-17-20 and 11-26-20. Medication staff documented on resident's MAR, medication pending prescription from physician.
3. Resident?s physician?s order dated 8-28-20 and MARs documented medication to be administered daily for 28 days, facility to call for refills.

Plan of Correction: After further investigation, there were 2 medication aides who were not aware of the location of the Junel FE medication and put in the exception "awaiting pharmacy delivery and/or pending prescription from physician." Administrator and/or designee will monitor MAR daily for any exceptions to ensure medications are being administered as prescribed. All medication aides will be instructed where non bingo card medications are stored to ensure all medication are given as prescribed. 4/15/21 and Ongoing

Standard #: 22VAC40-73-680-I
Complaint related: No
Description: Based on record review the facility failed to ensure the facility's medication administration record contained all required information.

Evidence:
1. Resident #1's October 2020 medication administration record (MAR) did not include the staff's initial/ was blank on 10-11-20 for the medication, Lexapine 50mg, scheduled at 5:00 p.m.
2. Further review of the October MAR, staff's initial was missing/blank on 10-11-20 for the medication, Lexapine Succinate 25mg, scheduled at 5:00 p.m. and to be given with the 50 mg to equal 75mg.


Based on record review, the facility failed to ensure the facility's medication administration record (MAR) contained all required information.

Evidence:
1. Resident #11's October 2020 medication administration record (MAR) did not include the staff's initial/was blank on 10-11-20 for the medication, Lexapine 50 mg, scheduled at 5:00 p.m.
2. Further review of the October MAR, staff's initial was missing/ blank on 10-11-20 for the medication Lexapine Succinate 25 mg, scheduled at 5:00 p.m.
3. Staff #1 acknowledged, the MAR did not include staff's initial for the aforementioned medications.

Plan of Correction: The Administrator and/or designee will monitor the MAR daily to ensure medication aides are administering all medications as prescribed. 3/29/21 and Ongoing

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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