VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Assisted Living at Lucy Corr
6800 Lucy Corr Boulevard
Chesterfield, VA 23832
(804) 748-1511

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: Jan. 11, 2022

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

Technical Assistance:

290.B -Staff In charge 610.B- Menu Posting 960.B - Emergency Evacuation Plan

Comments:

INSPECTION SUMMARY A renewal inspection was completed on 1/11/2022. The administrator was on site during the inspection. The census on the day of the inspection was 38 residents. Three resident and three staff files were reviewed for compliance, along with medication administration, required postings, fire and health inspections, facility maintenance and repair, etc. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and the violations are documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1100-C
Description:	Based on a review of three resident files on 1/11/2022, the facility failed to document that the order of priority was followed. Evidence: The Approval for Placement In Special Care Unit form for resident # 3 did not include an explanation of why written approval was not obtained from each individual higher on the list of priority.
Plan of Correction:	22VAC40-73-(10)-1100-C: No less than 100% audit of resident files for those residents residing in the Specialized Care Unit will be conducted by the Administrator, violations corrected, and will be accomplished by 1/31/2022. This is to ensure that an explanation of why written approval was not obtained from each individual higher on the list of priority is documented in the resident?s chart. All resident charts will be reviewed monthly by Administrator, Clinical Nurse Manager for compliance, beginning February 2022.
Standard #:	22VAC40-73-450-E
Description:	Based on a review of three resident files on 1/11/2022, the individualized service plan for one resident was not signed or dated by the resident or his legal representative. Evidence: The individualized service plan for resident # 3 was not signed or dated by the resident or her legal representative.
Plan of Correction:	22VAC40-73-(6)-450-E: ISP was created on 12/17/2021 in anticipation of resident # 3 returning to the community. Resident discharged by family and did not return. No less than 100% audit of current resident records. For any unsigned ISPs, Administrator and Clinical Nurse Manager will obtain signatures and/or confirmation of ISP review from legal representative or resident. Administrator and Clinical Nurse Manager will conduct audit and it will be accomplished by 1/27/2022. Will be corrected by 2/11/2022. All resident charts will be reviewed monthly by Administrator, Clinical Nurse Manager for compliance, beginning February 2022.
Standard #:	22VAC40-73-640-D
Description:	Based on an inspection of medication administration on 1/11/22, the facility did not have readily accessible at least one pharmacy reference book, drug guide, or medication handbook for staff who administer medications. Evidence: Staff was unable to locate at least one pharmacy reference book, drug guide, or medication handbook in the memory care unit.
Plan of Correction:	22VAC40-73-(6)-640-D: 2022 Drug Guides ordered. On 1/17/2022. One (1) Drug Reference guide placed in the resident records room on 1/14/2022. Violation was corrected on 1/14/2022. Remaining Drug Guides on order will be placed in conspicuous areas in the assisted living community and placed in medication carts for reference once they are delivered to the community. All Drug guides will be in place by 2/11/2022, Administrator and Clinical Nurse Manager will assess the status of Drug Guides in the community each quarter to determine if an adequate supply is on-hand and that they are up to date, beginning April, 2022. Administrator will reorder Drug Guides as indicated.
Standard #:	22VAC40-73-720-A
Description:	Based on a review of three residents' files on 1/11/22, the Do Not Resuscitate order for one resident was not included in the resident's individualized service plan. Evidence: Resident # 2 has a Do not Resuscitate Order dated February 2020. The Do Not Resuscitate order was not found in the resident's individualized service plan.
Plan of Correction:	22VAC40-73-(6)-720-A: Do Not Resuscitate order was added to resident # 2 ISP. This was corrected and accomplished on 1/15/2022. No less than 100% audit of current residents? ISPs will be conducted by Clinical Nurse Manager and the Administrator for correct code status. This will be accomplished by 1/31/2022. All resident ISPs will be reviewed monthly by Clinical Nurse Manager to ensure the correct code status is outlined in the ISP, beginning February 2022