VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Havenwood
50 Havenwood Drive
Lexington, VA 24450
(540) 463-2205

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Oct. 4, 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.

Technical Assistance:

To ensure that the facility had a thorough understanding of standards, the licensing inspector and the Administrator had a discussion regarding standards 270-1 and 980-H.

Comments:

A renewal inspection was initiated on 10/04/2021 and concluded on 10/06/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 11. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 2 resident records, 2 staff records, activities calendar, menu, most recent health care oversight, most recent health department and fire inspections, fire drills, most recent dietitian review of special diets and sworn disclosures and criminal record checks since the facility's last mandated inspection submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 10/06/2021. An exit interview was conducted with the Administrator on 10/06/2021, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance 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 resident record review and staff record review, the facility failed to ensure training for staff prior to being involved in the care of such residents for assisted living facilities that accept, or have in care, residents who are or who may be aggressive. EVIDENCE: 1. The ?Report of Resident Physical Examination? for resident 2, dated 07/16/2021, showed that the resident takes ?Seroquel BID for agitation?. Resident 2 was admitted to the facility on 08/11/2021. 2. The record for staff 1, date of hire 08/02/2021, did not contain documentation that staff 1 had aggressive behavior training prior to being involved in the care of residents who are or who may be aggressive. Interview with staff 3 confirmed that staff 1 did not have aggressive behavior training.
Plan of Correction:	All staff will have aggressive training completed by the administrator that are currently employed. All future staff will complete this training during the hiring process.
Standard #:	22VAC40-73-325-B
Description:	Based on resident record review and staff interview, the facility failed to ensure that the fall risk rating was reviewed and updated after a fall for residents who meet the criteria for assisted living care. EVIDENCE: 1. The licensing office was notified that on 04/08/2021 resident 1 had a fall, 911 was called, and resident 1 was taken to the ER. 2. The uniform assessment instrument (UAI), with an assessment date of 03/09/2021, assessed resident 1 as assisted living level of care. 3. The record for resident 1 did not contain documentation that the fall risk rating for the fall that occurred on 04/08/2021 had been reviewed and updated. 4. Interview with staff 3 revealed that the fall risk rating had not been reviewed and updated.
Plan of Correction:	The resident's fall risk was reviewed and newly dated although the risk remained the same as the resident was already a fall risk.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review and staff interview, the facility failed to complete the Uniform Assessment Instrument (UAI) as required. EVIDENCE: 1. The private pay UAI for resident 1, with a reassessment date of 05/07/2021, showed the resident needs mechanical help and human physical assistance with dressing. The individualized service plan (ISP), with a review date of 05/07/2021, showed resident 1 ?will have physical assistance with dressing with all articles of clothing?. Interview with staff 3 revealed that the ISP is correct and the UAI is incorrect. 2. The private pay UAI for resident 2, with a reassessment date of 08/30/2021, showed the resident takes medications without assistance. Interview with staff 3 revealed that the UAI is incorrect and that the facility administers medications to resident 2.
Plan of Correction:	The residents UAI was corrected and updated to show the appropriate changes for resident 1 and 2. Resident 1 needs physical assistance only. Resident 2 has all meds administered by the facility staff.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure that the Individualized Service Plan (ISP) addressed all of the identified needs. EVIDENCE: 1. Home health notes for resident 2 indicated that the resident uses a wheelchair. 2. The ISP for resident 2, with a review date of 09/29/2021, does not indicate that resident 2 uses a wheelchair. Interview with staff 3 confirmed that resident 2 uses a wheelchair.
Plan of Correction:	Resident 2's ISP was updated to include wheelchair use.
Standard #:	22VAC40-73-650-B
Description:	Based on resident record review, the facility failed to ensure that physician or other prescriber orders for administration of all prescription and over-the-counter medications and dietary supplements included the diagnosis, condition or specific indications for administering each drug. EVIDENCE: 1. The following physician?s orders for resident 1 do not include the diagnosis, condition or specific indications for administering the following medications: Glipizide ER 5 MG, dated 05/14/2021; Glipizide ER 2.5 MG, dated 06/07/2021; and Novolog 100U/ML Vial 10 ML, dated 08/24/2021. 2. The most recent physician?s order for resident 2, dated 09/30/2021, does not include the diagnosis, condition or specific indications for administering the following medications: Vitamin C 500 MG, Proscar 5 MG, Flomax 0.4 MG, Mevacor 40 MG, Aspirin EC 325 MG, Thera and Seroquel 50 MG.
Plan of Correction:	Facility Administrator and nurse are working with the pharmacy to come up with a plan to keep drs. orders compliant by including the diagnosis. We are also sending letters to all offices to ensure they understand this is required by VDSS DOL.
Standard #:	22VAC40-73-660-B
Description:	Based on observation from tour of the facility and resident record review, the facility failed to ensure that for a resident that had his own medication in his room the uniform assessment instrument (UAI) indicated the resident is capable of self-administering medication. EVIDENCE: 1. At approximately 11:00 AM during on-site inspection on 10/06/2021, the licensing inspector observed two bottles of Ketoconazole 2% shampoo in resident 2?s shower. The physician?s order, dated 09/30/2021, states ?Nizoral 2% Shampoo Ketoconazole 2% Shampoo apply to affected area 2 times weekly on Monday and Thursday? does not indicate that resident can self-administer this shampoo. 2. Interview with staff 3 revealed that resident 2 is not capable of self-administering medications and that the facility administers medications to resident 2.
Plan of Correction:	Facility Administrator spoke with all staff and RMAs about medications compliance and had all RMAs review the facility medication administration plan.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to ensure that the medication administration record (MAR) contained the dosage of all medications administered. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 08/24/2021, for ?Novolog 100U/ML VIAL 10 ML Inject insulin units subcutaneously with breakfast and at bedtime per SS: 200-249=2; 250-299=4; 300-349=6; 350-399=8; 400 or >=10. Notify MD if >350?. 2. The September 2021 MAR for resident 1 showed that on 09/25/2021 at 7:00AM Novolog was administered to the resident; however, the MAR did not show how many units of Novolog were administered. The September 2021 and October 2021 MAR for resident 1 showed that at 20:00PM (8:00PM) Novolog was administered to the resident; however, the MAR did not show how many units of Novolog were administered on the following dates : 09/01/2021, 09/05-06/2021, 09/08-14/2021, 09/16-17/2021, 09/21/2021, 09/23-26/2021, 09/28/2021, 09/30/2021, 10/01/2021, 10/03/2021 and 10/05/2021.
Plan of Correction:	The facility nurse modified the residents MAR to include an area to document the units administered.