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: June 14, 2021

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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 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 6/14/2021 and concluded on 6/17/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 51. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, Health care oversight, Dietician oversight, Fire and Health Inspections, Fire Drill Logs 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 #:	22VAC40-73-270-1
Description:	Based on a review of staff records, the facility failed to ensure that all direct care staff were trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. EVIDENCE: 1. The records for staff persons 1 and 4 does not contain documentation of the employees having current training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. The facility houses a mental health population with some residents who have agitation/aggressive behaviors.
Plan of Correction:	An aggressive behaviors training has been scheduled for 6/23/21 for the individuals that need it. Our pharmacy will be sending a nurse our to provide the training.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The uniform assessment instrument (UAI) dated 4/13/2021 in the record for resident 1 has documentation that the resident requires mechanical assistance with bathing but the ISP dated 5/28/2021 is inconsistent as it has that the resident is independent with this ADL. Also the ISP has documentation of the residents identified need for a diabetic diet and allergy to codeine but does not identify the services to be provided, who will provide the service, when and where the service will be provided and any expected outcomes. 2. The ISP dated 4/6/2021 in the record for resident 2 has documentation of the identified need for an allergy to metformin but does not identify services to be provided, who will be providing the services, when and where the service will be provided and any expected outcomes. 3. The ISP dated 1/23/2020 in the record for resident 4 has documentation of the identified need for a chopped diet but does not identify services to be provided, who will be providing the services, when and where the service will be provided and any expected outcomes.
Plan of Correction:	ISP?s where corrected on 6/17/21. The proper rows have been added for additional issues listed rather than just have the info listed at the top.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of staff records, the facility failed to ensure that a review of resident rights and responsibilities were conducted with each staff person annually. EVIDENCE: 1. The records for staff persons 2 and 4 do not contain documentation that an annual review of resident rights and responsibilities were conducted with these employees.
Plan of Correction:	An in-service on resident rights was conducted on 6/17/21 with the staff members missing the yearly review as well as staff present that day. Facility will have two refreshers a year in regards to resident rights.
Standard #:	22VAC40-73-680-D
Description:	Based on a review of resident records and medication administration records (MARs), the facility failed to ensure that medications were administered in accordance with physician instructions. EVIDENCE: 1. The June2021 MAR for resident 1 has a physician order dated 6/2/2021 for Venlafaxine HCL 75 mg, 1 tablet every day a bedtime. Staff initials are present for the administration of this medication at 8am and not at bedtime from 6/2/2021 through 6/7/2021.
Plan of Correction:	An In-service was conducted on 6-18-21 explaining what holes in the mar on and the proper way to document on the e-mar in regards to administered and non-administered. We will be having another in-service on the topic 6/24/21 with the med tech who missed the first one.
Standard #:	22VAC40-73-680-E
Description:	Based on a review of resident medication administration records (MARs), the facility failed to ensure that medical procedures ordered by a physician or other prescriber were provided according to his instructions and documented. EVIDENCE: 1. The May 2021 MAR for resident 2 has a physician order for blood pressure and heart rate checks every morning. The MAR does not have the recording of the results of the blood pressure or heart rate check on 5/16/2021, 5/19/2021 and 5/25/2021.
Plan of Correction:	An In-service was conducted on 6-18-21 explaining what holes in the mar on and the proper way to document on the e-mar in regards to administered and non-administered. We will be having another in-service on the topic 6/24/21 with the med tech who missed the first one.
Standard #:	22VAC40-73-680-I
Description:	Based on a review of resident medication administration records (MARs), the facility failed to ensure all required documentation on resident MARs. EVIDENCE: 1. The May 2021 MAR for resident 1 does not have staff initials for the administration of the prescribed medications Lantus Solostar 16 units at 8pm on 5/31/2021, Lovastatin 20mg at 8pm on 5/31/2021, Risperidone 2mg at 8pm on 5/31/2021, terazosin 2mg at 8pm on 5/31/2021 and Trazadone 100mg at 8pm on 5/31/2021. 2. The May 2021 MAR for resident 3 does not have staff initials for the administration of the prescribed medication Clonazepam 0.5mg at 4pm on 5/20/2021.
Plan of Correction:	An In-service was conducted on 6-18-21 explaining what holes in the mar on and the proper way to document on the e-mar in regards to administered and non-administered. We will be having another in-service on the topic 6/24/21 with the med tech who missed the first one.
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 employment for each employee. EVIDENCE: 1. The record for staff person 5, hired on 7/6/2020 did not contain a criminal history record report that was completed on or prior to the 30th day of employment.
Plan of Correction:	The Staff member was sent to HR on 6/21/21 to have a criminal history ran. Awaiting the results.