VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Greenspring Village
7470 Spring Village Dr
Springfield, VA 22150
(703) 923-4663

Current Inspector: Alexandra Roberts

Inspection Date: Feb. 22, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 complaint inspection was initiated on 02/22/2021 and concluded on 01/21/2022. A complaint was received by the department regarding allegations in the areas of Resident Care and Related Services, and Personnel, . The Assistant. Administrator of Continuing Care was contacted by telephone to conduct the investigation. The licensing inspector emailed the Assistant Administrator of Continuing Care a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaints but identified during the course of the investigation can be found on the violation notice. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s); and 4) date that that plan of correction will be completed. Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-40-A
Complaint related:	No
Description:	Based on documentation review, the facility failed to ensure that the licensee shall ensure compliance with all regulations for licensed assisted living facilities and with the facility's own policies and procedures. EVIDENCE: 1. Facility Policy 8614.12 Unusual Occurrences: Notification of Regulatory Agencies states "All unusual occurrences are reported as soon as possible to the State Licensing Agency" and includes "any condition or event which has or may compromise(d) the health or safety of the residents". 2. Facility Policy (not numbered) Call Bell System Response states "Nursing staff will manually clear all nurse calls within 15 minutes to prevent an overload of calls within the system, which in turn will prevent a delay in response time to the phone handsets".
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on interview and documentation, the facility failed to ensure that each facility shall report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. EVIDENCE: Clinical notes on 12/21/2020 at 11:05 a.m. document that Resident 1 was found "lying in the shower on the floor" and "writer called md on call...to inform about fall and abrasion" and "with AM nurse noted redness on resident abdominal region , facial cheeks and breast"; and Clinical notes on 12/21/2020 at 12:21 p.m. document "Resident (1) was reassessed and redness has increased...and blisters were observed...". The facility did not report the incident within 24 hours to the regional licensing office.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-70-C
Complaint related:	Yes
Description:	Based on interview and documentation review, the facility failed to ensure that the facility shall submit a complete written report of each incident specified in subsection A of this section to the regional licensing office within seven days from the date of the incident and the report shall be signed and dated by the administrator and shall include the following information: Name and address of the facility; Name of the resident involved in the incident; Date and time of the incident; Description of the incident, the circumstances under which it happened, and the extent of injury; Location of the incident; Actions taken in response to the incident; Actions to prevent recurrence of the incident, if applicable; Name of staff person in charge at the time of the incident; Names, telephone numbers, and addresses of witnesses to the incident, if any; and Name, title, and signature of the person making the report, if other than the administrator, and date of the completion of the report. EVIDENCE: As specified in subsection A of this section, the facility did not submit a complete report on Resident 1's incident that occurred on 12/21/2020 to the regional licensing office within seven days.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that the comprehensive Individualized Service Plan (ISP) shall include description of identified needs and date identified based upon the Uniform Assessment Instrument (UAI), admission physical examination and other sources. EVIDENCE: Resident 1's ISP differs from other sources in the following areas: 1. Wheeling: Resident 1's Physical Examination Report dated 11/23/2020 documents that the resident "ambulatory via WC" (wheelchair) and "uses WC"; the UAI dated 11/24/2020 documents a need for help wheeling "human help only, supervision" and does not document the need for physical assistance and mechanical help; Staff 5 reported in Clinical Notes dated 11/25/2020 at 9:00 PM that the resident "came in a W/C" upon admission"; Resident 1's ISP dated 11/25/2020 documents Resident 1 "will use her transport chair for mobility and will need staff assistance to push her." 2. Bathing and Toileting: Resident 1's UAI dated 11/24/2020 documents resident needs help with Bathing and Toileting as "human help only, physical assistance" and does not document a need for mechanical help; Resident 1's ISP dated 11/25/2020 documents a "shower chair / stool" and a "safety handrail frame for toilet" as needed mechanical devices in addition to "standby or hands-on assistance" in bathing and bathroom. 3. Walking: Resident 1's UAI dated 11/24/2020 documents resident needs help Walking as "human help only, supervision" and does not document a need for mechanical help; Staff 6 reported on Clinical Notes dated 11/26/2020 at 7:28 AM that "resident ambulated on hall way with walker with private aid" and Staff 7 reported on Clinical Notes on 11/26/2020 at 12:23 PM "Has a private sitter with her...Noted using her walker to the bathroom and within her room." Resident 1's ISP dated 11/25/2020 documents a needed device "wheelchair (manual) walker" and staff will need to provide stand-by supervision when (resident) is using her walker for mobility" and assistance from private aid is not documented in addition to the staff for walking.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-460-B
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that care provision and service delivery shall be resident-centered to the maximum extent possible and shall include prompt response by staff to resident needs as reasonable to the circumstances. EVIDENCE: Facility's call history dated between 11/25/2020 and 12/21/2020 for Resident 1's floor EV-1 documented 72 calls logged and: 1. 5/72 calls were cancelled between 1-3 hours, 2. 11/72 calls were cancelled between 31-59 minutes, 3. 14/72 calls were cancelled between 16-30 minutes, 4. and 42/72 calls were cancelled between 1-15 minutes.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-460-D
Complaint related:	No
Description:	Based on record review and interview, facility failed to ensure that the facility shall provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls. EVIDENCE: 1. On 12/21/2020 Resident 1 was found alone and unsupervised on the resident's bathroom shower floor. 2. Clinical Notes e-signed by Staff 4 on 12/21/2020 at 11:05 AM documented "Writer noted water on hallway floor went into resident's room noted her in sidelying position with her head facing shower nozzle and her feet facing side wall with water running inside shower."; and also "AM nurse noted redness on resident abdominal region , facial cheeks and breast." On 12/21/2021 at 12:21 PM, Staff 4 documented "Resident was reassessed and redness has increased to lower extremities and blisters were observed on her back, and chest" and it was decided to send resident to hospital. 3. Resident 1's Uniform Assessment Instrument dated 11/24/2020 shows Resident 1 needs help for bathing with "Human Help Only, Physical Assistance". 4. Resident 1's Individualized Service Plan signed by staff and family on 11/25/2020 documents "Staff will need to provide hands on assistance throughout her entire bathing routine."
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-580-E
Complaint related:	No
Description:	Based on interview and documentation, the facility failed to ensure that the facility shall implement a policy to monitor each resident for compliance with any needs determined by the resident's Individualized Service Plan (ISP). EVIDENCE: Resident 1's Individualized Service Plan dated 11/25/20220 documents that resident requires "assistance with bathing, hands-on" at a frequency of "1-2 times per week"; and Staff 1 informed Licensing Inspector that residents are offered showers on specific days however the facility does "not keep records of the date/time offered and if it was given."
Plan of Correction:	Not available online. Contact Inspector for more information.