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Fillmore Place
36 West Fillmore Street
Petersburg, VA 23803
(804) 732-1327

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: Dec. 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
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.

Comments:
An unannounced renewal inspection was conducted by the Licensing Inspector and the Licensing Administrator on December 14, 2021 from 10:00 a.m.-2:00 p.m. A census of 80 residents was reported. A sample of 11 resident records and 5 staff records were reviewed as well as facility postings and other facility documentation. A tour of the facility was conducted to include observance of buildings and grounds as well as resident rooms. A medication pass was observed and Medication Administration Records/physician?s orders were reviewed. The lunch meal was also observed. The violations cited are identified in this report. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it to the licensing office within 10 calendar days. Please specify how the violation will be corrected. The plan must contain: 1) step(s) to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation during this inspection. I can be reached at Kimberly.M.Davis@dss.virginia.gov or (804) 662-7578.

Violations:
Standard #: 22VAC40-73-200-D
Description: Based on a review of staff records, the facility failed to obtain a copy of the certificate issued or other documentation indicating the person has met one of the requirements for direct care staff and it is part of the staff member?s record.


Evidence:
Staff #1?s record did not contain documentation of direct care staff training.

Plan of Correction: All direct care staff will completed all required training.

Standard #: 22VAC40-73-210-F
Description: Based on a review of staff records, the facility failed to ensure that at least two hours of training focused on infection control and at least four hours focused on topics related to residents? mental impairment when adults with mental impairments reside in the facility.


Evidence: Five of five staff (dates of hire for staff: 4-18-18, 2-10-14, 2-28-19, 4-12-19, 10-18-21) training records reviewed did not include the annual training requirement of two hours focused on infection control and four hours focused on residents? mental impairment .

Plan of Correction: Administrator will ensure that two hours of staff training on infection control and four hours on topics related to mental impairment will be completed annually.

Standard #: 22VAC40-73-250-C
Description: Based on a review of staff records, the facility failed to ensure that it maintained all required personal and social data.


Evidence: The record for Staff # 1 (date of hire: 4-18-18) did not contain the name and telephone number of an emergency contact.

Plan of Correction: Administrator to ensure all required paperwork will be in staff records.

Standard #: 22VAC40-73-260-A
Description: Based on a review of staff records, the facility failed to ensure that each staff member maintained current certification in first aid.


Evidence: First aid certification for Staff # 1 (date of hire: 4-18-18) was last dated 6-27-19.

Plan of Correction: All staff will complete first aid certification.

Standard #: 22VAC40-73-310-D
Description: Based on a review of resident records the facility failed provide written assurance to the resident that the facility has the appropriate license to meet his care needs at the time of admission.


Evidence: The written assurance for Resident #2, #3, #4, and #6, who transferred to the facility on 9/27/2021, did not indicate whether the facility does or does not have the appropriate license to meet the resident?s care needs. The UAI written Assurance Form contained an area to be checked for ??the results indicate that this facility ___ does _____ does not have the appropriate license to meet this person?s Activities of Daily Living (ADLs)?.? that was blank.

Plan of Correction: Administrator will ensure all intake/admission paperwork is in resident records.

Standard #: 22VAC40-73-320-A
Description: Based on a review of resident records, the facility failed to obtain a physical examination report, including the results of a risk assessment documenting the absence of tuberculosis in a communicable form, within the 30 days prior to admission.



Evidence:
New physical examination reports were not obtained for Resident #2, Resident # 4, Resident # 5, and -Resident # 6 who all transferred from another assisted living facility and were admitted on 9-27-21.

Resident #6?s Report of TB Screening form in the resident record was dated 5/11/2020.

Resident #5?s Report of Tuberculosis Screening form in the resident record was dated 10/8/2020.

Resident #4?s Report of TB Screening form in the resident record was dated 03/22/21.

Resident #2?s Report of Resident Physical Examination and Report of TB Screening forms in the resident record were dated 3/22/2021.

Plan of Correction: Administrator will ensure TB screenings are completed per DSS required time line.

Standard #: 22VAC40-73-350-B
Description: Based on a review of resident records, the facility failed to ascertain, prior to admission whether a potential resident is a registered sex offender and document in the resident?s record that this was ascertained and the date the information was obtained.


Evidence: The record for Resident # 1 and Resident # 2, both admitted on 9-27-21, did not contain sex offender screening information.

Plan of Correction: Administrator will retrain Intake Coordinator on admission paperwork and will ensure its completeness.

Standard #: 22VAC40-73-380-A
Description: Based on a review of resident records, the facility failed to ensure that prior to or at the time of admission, personal and social data information was obtained was obtained.


Evidence: The records for Resident # 1 (date of admission: 9-27-21), Resident # 2 (date of admission: 9-27-21), Resident # 4 (date of admission: 9-27-21), and Resident # 5 (date of admission: 9-27-21) contained incomplete personal and social data information.

Plan of Correction: Administrator will ensure all intake/ admission paperwork is complete in resident records.

Standard #: 22VAC40-73-390-A
Description: Based on a review of resident records the facility failed to ensure that there was a written agreement/acknowledgement of notification dated and signed by the resident or applicant for admission or the appropriate legal representative, and by the licensee or administrator.


Evidence: The record for Resident # 6 (date of admission: 9-27-21) contained a resident agreement that was not dated by the resident and was not signed or dated by the licensee or administrator.

Plan of Correction: Administrator will ensure all intake /admission papers are completed.

Standard #: 22VAC40-73-410-A
Description: Based on a review of resident records the facility failed to ensure that acknowledgement of having received the orientation was signed and dated by the resident.


Evidence: The record for Resident # 4 (date of admission: 9-27-21) contained an acknowledgment of orientation that was signed but not dated by the resident.

Plan of Correction: Administrator will ensure all intake/admission papers are completed.

Standard #: 22VAC40-73-440-A
Description: Based on a review of resident records, the facility failed to ensure that the Uniform Assessment instrument (UAI) is completed at least annually.


Evidence:
-UAI for Resident # 1 (admit date: 9-27-21) was dated 6-24-2020.
- Resident #4?s record contained a uniform assessment instrument dated 09/20/2020.

Plan of Correction: Administrator will be more diligent in ensuring UAIs are completed annually.

Standard #: 22VAC40-73-450-C
Description: Based on a review of resident records, the facility failed to ensure that the comprehensive individualized service plan (ISP) that contained a written description of what services will be provided to address identified needs based on the Uniform Assessment Instrument (UAI).


Evidence:
Resident # 1?s Uniform Assessment Instrument (UAI) notes resident needs supervision with bathing. The individualized service plan (ISP) noted the date of identified need as 9-27-21 for bathing. The description of need notes two options of ?able? and ?unable to safely bathe independently?. The box ?able? was checked for bathing. The UAI notes no help is needed with dressing, however, the services to be provided on the ISP note ?Gather necessary supplies. Explain procedure to resident. Cue resident to assist where he/she can. Provide privacy and warmth. Assist in/out of tub/shower. Inspect skin for rashes, wounds and bruises. Assist resident with drying, applying lotion and dressing appropriately.? The UAI also noted that resident needs help with transportation and shopping, but those identified needs were not addressed on the ISP.

Resident # 2?s UAI notes resident needs supervision with bathing and dressing. The ISP noted the date of identified need as 9-27-21 for bathing and dressing. The description of need notes two options of ?able? and ?unable to safely bathe independently? or ?unable to dress independently.? The box ?able? was checked for both bathing and dressing. The services to be provided on the ISP for bathing note ?Gather necessary supplies. Explain procedure to resident. Cue resident to assist where he/she can. Provide privacy and warmth. Assist in/out of tub/shower. Inspect skin for rashes, wounds and bruises. Assist resident with drying, applying lotion and dressing appropriately.? The services to be provided for dressing note ?Assist with appropriate clothing selection allowing resident?s input and preference. Staff will assist resident with dressing, allowing maximum participation from resident.? The UAI also noted that resident needs help with transportation and shopping, but those identified needs were not addressed on the ISP.

Resident #6?s UAI notes resident needs supervision with bathing and dressing. The individualized service plan noted the date of identified need as 9/27/2021 for bathing and dressing. The description of need notes two options of ?able? and ?unable to safely bathe independently? or ?unable to dress independently.? The box ?able? was checked for both bathing and dressing. The UAI notes no help is needed with toileting. The ISP identified resident as ?able? with toileting on 9/27/2021 but the services to be provided note to ?cue the resident and direct to bathroom every 2 hours as needed and to monitor resident for cleanliness/appropriate hygiene after toileting.?

Resident #5?s UAI notes mechanical help needed for bathing, dressing, toileting, transferring, wheeling, and mobility and notes ?He can perform ADL?s independently with Mechanical Assistance?. The ISP noted the date of identified need as 9/27/2021 for bathing, dressing, and toileting. The description of need notes two options of ?able? and ?unable to safely bathe independently? or ?unable to dress independently.? The box ?able? was checked for, bathing, dressing, and toileting. The Services to be Provided noted on the ISP do not address mechanical assistance.

**Due to the volume of information gathered during the inspection, a separate document has been created and is available upon request.**

Plan of Correction: Administrator will ensure that ISPs are completed per assessed UAI needs.

Standard #: 22VAC40-73-450-E
Description: Based on a review of a resident records, the facility failed to ensure that the Individualized Service Plan (ISP) was signed and dated by the person who developed the plan and by the resident or his legal representative.


Evidence: The ISP for Resident # 2 (admit date: 9-27-21) indicating a creation date of 9-27-21 was not signed/dated by the resident or his legal representative and was signed by the administrator but not dated.
-The most recent ISP for Resident # 3 (admit date: 3-27-18) indicating a creation date of 3-27-21 contained no signatures or dates.

Plan of Correction: Administrator will ensure that ISPs are signed and dated by the staff person who developed the plan and the resident or his legal representative.

Standard #: 22VAC40-73-450-F
Description: Based on a review of resident records, the facility failed to ensure that individualized service plans (ISP) were reviewed and updated at least once every 12 months.


Evidence:
Resident #11?s (date of admission 10-1-2008) record contained the most recent ISP signed by the facility representative on 8-30-2018. The ISP had sticky note on it stating, ?Need New One.?

Plan of Correction: Administrator will ensure that ISPs are completed yearly.

Standard #: 22VAC40-73-640-A
Description: Based on an observation of the medication pass, the facility failed to ensure it implemented its medication management plan to prevent the use of contaminated medications.


Evidence:
During a medication pass, two licensing staff members observed Staff # 2 drop a medication on the floor. Staff # 2 picked the medication off the floor and placed it back in the souffle cup and walked toward the resident to administer the medication. Licensing staff intervened and informed staff # that she could not administer the medication that fell on the floor. Staff # 2 stated that she would give the resident the dose from Monday that he did not receive.

Plan of Correction: Med Tech was reprimanded and reminded to dispose of any medication that may be dropped.

Standard #: 22VAC40-73-650-E
Description: Based on a review of resident records, the facility failed to ensure that each resident?s record contained the physician?s or other prescriber?s signed written order.


Evidence: The facility did not have any signed physician?s orders for Resident # 1, #2, #3, and # 4 observed during med pass. The facility provided licensing staff with pharmacy print-outs that were not signed or electronically signed by a physician or other prescriber.

Plan of Correction: Administrator will ensure meds are signed by prescriber and Med Tech.

Standard #: 22VAC40-73-700-2
Description: Based on a tour of the facility, the facility failed to post ?No Smoking-Oxygen in Use? signs and enforce the smoking prohibition in any room where oxygen is in use.


Evidence: An oxygen device was observed by licensing staff in Room # 37, however, there was no ?Oxygen in Use? sign posted.

Plan of Correction: Administrator will ensure a sign is posted.

Standard #: 22VAC40-73-750-B
Description: Based on a tour of the facility, the facility failed to ensure that each resident room contained an operable lamp and a table or its equivalent accessible to each bed.


Evidence:
-Licensing staff observed that there was only one bedside table in Room # 2, which contained two beds. There was only one lamp, which was on the counter by the closet and it did not contain a light bulb.
-Room # 41 contained two beds, but only one bedside table and one lamp.
-Room # 19 contained two beds, but only one lamp.
-Room # 6 contained one lamp that did not have a light bulb.

Plan of Correction: Administrator will speak with Licensee and purchase more lamps/light bulbs, and furniture as needed.

Standard #: 22VAC40-73-750-E
Description: Based on a tour of the facility, the facility failed to ensure that bed linens were in good repair so that residents always have clean sheets and pillowcases.


Evidence: Licensing staff observed the sheets on the bed by the window were soiled and the sheets and pillows on both beds were dirty in Room # 19. Photograph evidence was taken.

Plan of Correction: Administrator will advise licensee to purchase more linen quarterly or as needed.

Standard #: 22VAC40-73-870-A
Description: Based on a tour of the facility, the failed to ensure that the interior and exterior of the building is maintained in good repair and kept clean and free of rubbish.



Evidence:
-There was a hole in the door of Room # 43 with a jacket hanging out of the hole.
-Two fist- sized holes (that appeared to be punched) were in the wall in the hallway on the third floor. Staff # 6 confirmed that a resident had punched the wall.
-A ceiling tile was hanging down in the bathroom between Room # 1 and Room # 2.
-Damaged wall, chipped paint, and ceiling damage around the window in Room # 37. There were also several large full plastic drawstring bags near the bed by the door.
-Large window was boarded up in the hallway with exposed wires on the third floor.
(Photograph evidence was taken of these areas.)

Plan of Correction: Administrator will ensure maintenance completes repairs in a timely fashion.

Standard #: 22VAC40-73-870-B
Description: Based on a tour of the facility, the facility failed to ensure that it was free from foul, stale, musty odors.


Evidence: Licensing staff noted a strong urine odor in Room # 41.

Plan of Correction: Housekeeping will increase checking each floor for odors to 3 times a day.

Standard #: 22VAC40-73-870-D
Description: Based on a tour of the facility, the facility failed to keep the building free of infestations of insects.


Evidence: Active bed bugs were observed by licensing staff in both beds in Room # 19. Licensing staff also observed bed bugs crawling on the wall near the bed by the door. Photograph evidence was taken.
-Gnats were also observed flying throughout the facility.

Plan of Correction: Administrator will advise Licensee and pest control company of bugs. Staff will also clean and spray for bugs.

Standard #: 22VAC40-73-925-A
Description: Based on a tour of the facility, the facility failed to ensure that toilet tissue was accessible to each commode and soap was accessible to each face/hand washing sink.


Evidence: Licensing staff observed that the bathroom between Room # 1 and Room # 2 did not contain soap or toilet issue.

Plan of Correction: Administrator will remind housekeeper to make sure hygiene supplies are accessible to residents.

Standard #: 22VAC40-73-925-B
Description: Based on a tour of the facility, the facility failed to ensure that common face/hand washing sinks had paper towels or an air dryer.


Evidence: Licensing staff observed that the bathroom between Room # 1 and Room # 2 did not contain paper towels or an air dryer.

Plan of Correction: Administrator will remind housekeeper to make sure supplies are accessible to residents.

Standard #: 22VAC40-73-990-C
Description: Based on a review of facility documentation the facility failed to ensure that it maintained documentation of all staff currently on duty on each shift participating in an exercise in which procedure for resident emergencies are practiced at least once every six months.


Evidence: The facility did not have documentation of practice exercises for resident emergencies. Staff # 6 stated that the practice exercises are conducted but that they do not document that they are completed.

Plan of Correction: Administrator will ensure that practice exercises are clearly documented.

Standard #: 22VAC40-90-40-B
Description: Based on a review of staff records, the facility failed to ensure that a criminal history report was obtained on or prior to the 30th day of employment for each employee.


Evidence: Five out of five staff records reviewed did not contain criminal history reports. All five records contained Virginia Criminal History Record/Sex Offender & Crimes Against Minors Registry Search forms from Virginia State Police that had only the facility information completed. Staff # 6 stated that she thought they were in the record but that the facility?s corporate office may have kept them.

Plan of Correction: Corporate Office will share background checks with Administrator for employee records.

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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