VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Elance at Tuckahoe
567 N. Parham Road
Henrico, VA 23229
(804) 554-3939

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: March 7, 2022 and March 9, 2022

Complaint Related: No

Comments:

An unannounced 60 day monitoring inspection was initiated at the facility on 03/07/2022 during the approximate time of 10:23 a.m. and 1:30p.m. Upon the arrival of the inspector to the facility on 03/07/2022 facility staff reported that there was no facility Administrator of record. Facility staff also reported that a total of twenty-eight residents were in care to include the nine residents on the facility?s safe and secure environment. While the inspector was on site the Administrator for a licensed assisted living facility associated with the Licensee came onsite to assist with the inspection. Some but not all standards were reviewed for compliance. The inspector initiated the review of 3 resident records, 3 staff records, physician's orders, and medication administration records as well as conducting a tour of the physical plant accompanied by facility staff. A review of some policies and procedures as well as current Standards for Licensed Assisted Living Facilities was also discussed with the visiting Administrator. The visiting Administrator reported that a licensed facility Administrator was scheduled to start at the facility on 03/08/2022. The possible noncompliance revealed on 03/07/2022 was discussed with the visiting Administrator as well as the inspector?s observation of a delivery individual entering the facility not participating in the facility?s COVID-19 screening protocol. The visiting Administrator was informed that the inspection would resume at a later date. The onsite inspection conducted at the facility on 03/09/2022 was conducted between the approximate time of 9:24a.m and concluded at 12:50p.m. The new facility Administrator was onsite upon the arrival of the inspector. The inspector concluded the review of resident and staff records as well a review of the noncompliance revealed on 03/07/2022 with the new Administrator. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. An exit interview was conducted where findings of 03/07/2022 and 03/09/2022 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. Please contact me at Angela.r.reaves@dss.virginia.gov or (804) 840-0253 if you have any questions

Violations:

Standard #:	22VAC40-73-1130-A
Description:	Based on the review of facility records and staff interviews conducted on 03/09/2022 the facility failed to ensure that at least two direct care staff members are awake and on duty at all times in each special care unit who shall be responsible for the care and supervision of the residents. Evidence: 03/09/2022: The facility?s February 2022 staffing scheduled that was submitted for the inspector?s review did not identify that two direct care staff were assigned to the facility?s safe and secure environment on the 27th during the 3-11 and 11-7shifts; 28th during the 3-11 shift; The facility?s March 2022 staffing scheduled did not identify that two direct care staff were assigned to the safe and secure environment on March 1, 2022 during the 3-11 and the 11-7 shifts; March 2nd during the 3-11 and 11-7 shifts and March 5th during the 3-11 shift.
Plan of Correction:	FACILITY RESPONSE "Staffing shall meet the requirements as outlined in the Standards for Licensed Assisted Living Facilities. Staffing schedules will be reviewed by the Director of Health and Wellness to ensure appropriate coverage. The Executive Director and Director of Health and Wellness will review schedules monthly to ensure compliance."
Standard #:	22VAC40-73-150-A
Description:	Based on the interviews conducted the facility failed to ensure that the facility had an administrator of record. Evidence: 03/07/2022: Facility staff reported during interviews conducted while on site at the facility that the previous facility Administrator?s last day onsite was 02/23/2022. The visiting facility Administrator facility staff #1- also confirmed that the facility has been operating without a licensed facility Administrator since 03/24/2022 and that a new Administrator was scheduled to start on 03/08/2022. For twelve days beginning 02/24/2022 until 03/08/2022 the Licensee did not ensure that an individual was onsite that met the qualifications as the individual that would be responsible for the day to day operation and management of the facility as required in the current Standards for Licensed Assisted Living Facilities.
Plan of Correction:	FACILITYRESPONSE "The facility reported to the regional licensing office on March 8, 2022 that the Administrator?s last day was February 23, 2022. The licensee will ensure that the regional licensing office is immediately notified of any future changes in the Administrator and that there is always a licensed Administrator onsite that meets the qualifications as outlined by the Standards for Licensed Assisted Living Facilities."
Standard #:	22VAC40-73-150-A
Description:	Based on the interviews conducted the facility failed to ensure that the facility had an administrator of record. Evidence: 03/07/2022: Facility staff reported during interviews conducted while on site at the facility that the previous facility Administrator?s last day onsite was 02/23/2022. The visiting facility Administrator facility staff #1- also confirmed that the facility has been operating without a licensed facility Administrator since 03/24/2022 and that a new Administrator was scheduled to start on 03/08/2022. For twelve days beginning 02/24/2022 until 03/08/2022 the Licensee did not ensure that an individual was onsite that met the qualifications as the individual that would be responsible for the day to day operation and management of the facility as required in the current Standards for Licensed Assisted Living Facilities.
Plan of Correction:	FACILITY RESPONSE "The facility reported to the regional licensing office on March 8, 2022 that the Administrator?s last day was February 23, 2022. The licensee will ensure that the regional licensing office is immediately notified of any future changes in the Administrator and that there is always a licensed Administrator onsite that meets the qualifications as outlined by the Standards for Licensed Assisted Living Facilities."
Standard #:	22VAC40-73-150-B
Description:	Based on the review of emails received at the department and interviews conducted the facility failed to immediately notify the Virginia Board of Long-Term Care Administrators that the licensed administrator resigned, and that a new licensed administrator has been employed or that the facility is operating without an administrator licensed by the Virginia Board of Long-Term Administrators, whichever is the case, and provide the last date of employment of the previous licensed administrator. Evidence: Upon request the facility did not submit for the inspector?s review documented evidence that Board Long Term Care Administrators (VLTCA) were notified that the facility is operating without a licensed assisted living facility administrator beginning 02/24/2022
Plan of Correction:	FACILITY RESPONSE " The Licensee will ensure that the Department of Health Professions is notified of any future changes in Administrator."
Standard #:	22VAC40-73-290-A
Description:	Based on the review of facility records and staff interviews conducted the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time and failed to note any absences, substitutions on the schedule. Evidence: The facility?s staff scheduled for February and March 2022 is not consistently documented to identify facility staff that is scheduled to work at the facility. For example, on 03/07, 09, 10/2022 the facility schedule notes for the 3-11 shift ?CNA, Agency?.
Plan of Correction:	FACILITY RESPONSE "The staff schedule has been corrected to reflect the name and job classifications of all staff working on each shift. The Executive Director will monitor monthly for compliance."
Standard #:	22VAC40-73-460-B
Description:	Based on the review of facility records the facility failed to ensure that the facility provided prompt response to the resident?s needs as reasonable as possible. Evidence: Resident #3- The resident?s 02/01/2022 Uniform Assessment Instrument (UAI) that was submitted for the inspector?s review on 03/07/2022 notes that the resident needs a psychological evaluation but the facility did not submit for the inspector?s review documentation that the facility has followed up and secured the services for the resident.
Plan of Correction:	FACILITY RESPONSE "The facility will conduct a mini-mental evaluation on the resident as indicated on the Uniform Assessment Instrument (UAI). The Director of Health and Wellness and/or Executive Director will review every UAI and ensure that resident?s needs are promptly addressed."
Standard #:	22VAC40-73-460-B
Description:	Based on the review of facility records the facility failed to ensure that the facility provided prompt response to the resident?s needs as reasonable as possible. Evidence: Resident #3- The resident?s 02/01/2022 Uniform Assessment Instrument (UAI) that was submitted for the inspector?s review on 03/07/2022 notes that the resident needs a psychological evaluation but the facility did not submit for the inspector?s review documentation that the facility has followed up and secured the services for the resident.
Plan of Correction:	FACILITY RESPONSE "The facility will conduct a mini-mental evaluation on the resident as indicated on the Uniform Assessment Instrument (UAI). The Director of Health and Wellness and/or Executive Director will review every UAI and ensure that resident?s needs are promptly addressed. "
Standard #:	22VAC40-73-640-A
Description:	Based on the review of facility records the facility failed to ensure that the facility keep current, and implement a written plan for medication management that includes procedures for administering medication and methods to ensure that each resident's prescription medications and any over-the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: Resident #1 ? Facility staff documented on the facility medication administration record (MAR) charting for 01/22/2022 -01/31/22 that the 50mg of the medication Fluticasone to be administered to the resident at 9:00a.m was not administered to resident #1 on 01/23, 24, 25, 26/2022; noting that the medication was ?not available?. ? Facility staff documented on the medication administration record (MAR) charting for 01/23, 24, 25, 26/2022 that resident #1 was not administered the 10mg of the medication Loratidine on 01/23/2022 at 9:00a.m. ? Facility staff documented on the medication administration record (MAR) charting for 01/23, 24, 25, 26/2022 that resident #1 was not administered the one tablet multivitamin on 01/23/2022 at 9:00a.m documenting that the medication was ?not available, not given.?
Plan of Correction:	FACILITY RESPONSE "All nurses and medication aides will be re-educated on the facility?s medication management plan. Random monitoring of compliance will be completed a minimum of one time per week by the Executive Director, Director of Health and Wellness, or designee to ensure continued compliance. The Director of Health and Wellness or designee will monitor medication administration records a minimum of once daily to monitor medication administration and will observe a medication pass weekly to ensure continued compliance"
Standard #:	22VAC40-73-870-I
Description:	Based on observation of the facility on 03/09/2022 the facility failed to ensure that the elevators, where used, is kept in good running condition. Evidence: The facility elevator near the safe and secure environment was observed to have a sign posted stating that the elevator was out of order.
Plan of Correction:	TFACILITY RESPONSE "he elevator was repaired on the same day that it malfunctioned (3/9/22). The facility does have a second set of elevators and residents and staff were notified that the second elevator was available for use until the elevator near the safe and secure environment was repaired. The Executive Director and Plant Operations Director will ensure that elevator inspections are conducted as required."