VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cave Creek ALF
8088 Lee Highway
Troutville, VA 24175
(540) 992-4599

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: Nov. 1, 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:

A renewal inspection was initiated on 10/28/2021 and concluded on 11/1/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 27. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 3 resident records, 3 staff records, activities calendar, staff schedules, Health and Fire inspections, Health care and dietician oversight, facility fire drill logs submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 11/1/2021. An exit interview was conducted with the Administrator on the date of inspection, 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 #:	22VAC40-73-450-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 record for resident 2 has documentation that the resident has a diagnosis of schizophrenia and PTSD. In an interview with staff person 4 on 11/1/2021 it was expressed that resident 2 sees a mental health provider through the Veterans Administration. The ISP dated 7/17/2021 in the record for resident 2 does not address the identified need for mental health services.
Plan of Correction:	The residents ISP was updated to reflect the identified need for mental health services.
Standard #:	22VAC40-73-640-A
Description:	Based on observations made of the facility medication room, the facility failed to ensure that medications were properly dated to ensure that they are not used past expiration dates. EVIDENCE: 1. An open Novolog Flexpen was noted to be in use for resident 2 on the day of inspection. The Flexpen did not have an open date to ensure that is would be discarded within the manufacturers required 28 days after opening.
Plan of Correction:	A new flexpen was opened and dated. The correct procedure was reviewed with the medications aides by the administrator.
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during an on-site inspection conducted on 11/1/2021, the facility failed to maintain the interior of the building in good repair. EVIDENCE: 1. The door leading to the courtyard across from room 15 was noted to have a shattered window pane. 2. The base board heater in the hallway across from room 19 was noted to be loose from the wall and the heating elements were exposed. 3. Peeling paint was observed on the ceiling in the hallway outside of room 26.
Plan of Correction:	The shattered window pane will be replaced. The base board heater was tightened to the wall. The ceiling will be repainted.
Standard #:	22VAC40-73-880-B
Description:	Based on observations made during an on-site inspection conducted on 11/1/2021, the facility failed to ensure that portable heating units either vented or unvented, were used only to provide or supplement heat in the event of a power failure or similar emergency. EVIDENCE: 1. Room 19 was observed to have an electric portable heater turned on/in use by the second bed on the day of inspection.
Plan of Correction:	The portable heater was removed.
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 3, hired on 4/28/2021, has documentation that the employees criminal record check was not received back to the facility until 6/7/2021. It was noted on the facility employee schedule that staff person 2 worked on 5/29/2021, 5/30/2021, 6/3/2021 and 6/4/2021, which were shifts worked past the 30 day requirement for obtaining a criminal record check.
Plan of Correction:	The administrator will ensure criminal back ground checks are received within the 30 day requirement.