VIRGINIA DEPARTMENT OF SOCIAL SERVICES

August Healthcare at Richmond
1503 Michaels Road
Henrico, VA 23229
(804) 288-6245

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: April 6, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

An unannounced renewal inspection was conducted by a licensing inspector on April 6, 2022 from 9:00 a.m. to 1:03 p.m. There were 16 residents in care. A tour of the building was conducted, first aid kit checked, medication administration observation observed, lunch meal was observed. Resident and staff records were reviewed, and resident and staff interviews were conducted. Violations were cited in the areas of buildings and grounds, admission, retention, and discharge of residents, and emergency preparedness. Thank you for your cooperation during this inspection. I can be reached at alex.poulter@dss.virginia.gov or (804)662-9771.

Violations:

Standard #:	22VAC40-73-430-H-1
Description:	Based on record review and interview with staff, the facility failed to ensure the discharge statement contained the date on which the resident, his legal representative, or designated contact person was notified of the planned discharge and the name of the legal representative or designated contact person who was notified; the actions taken by the facility to assist the resident in the discharge and relocation process; and the date of the actual discharge from the facility and the resident's destination. Evidence: 1. Resident #2?s date of discharge from the facility was 3-18-2022. Resident #3?s date of discharge from the facility was 2-02-2022. Neither Resident #2?s or Resident #3?s discharge statements contained the date on which the resident, his legal representative, or designated contact person was notified of the planned discharge and the name of the legal representative or designated contact person who was notified; the actions taken by the facility to assist the resident in the discharge and relocation process; and the date of the actual discharge from the facility and the resident's destination. 2. Staff #1 confirmed during interview that the two residents? statements did not contain the required information.
Plan of Correction:	1. Resident #2 and Resident #3 discharge statements have been completed. 2. A review of all resident?s discharge statements have been completed for the past 30 days. 3. The Administrator will educate the Social Worker and Admissions Coordinator on the importance of the discharge statements being completed prior to the discharge of the resident. 4. The Administrator/Designee will complete audits of the discharge statements being completed prior to the discharge of the resident. Quality Monitoring to be conducted monthly X3 months and as needed thereafter. Findings to be reported to the QAPI committee monthly and updated as indicated. Quality monitoring scheduled modified based on findings. Findings of the facility?s audit will be presented monthly for three months to the Quality Assurance Improvement Committee (QAPI) to ensure compliance.
Standard #:	22VAC40-73-870-E
Description:	Based on observation and interview with residents and staff, the facility failed to ensure all sinks were kept clean and in good repair and condition. Evidence: 1. During a medication administration observation of Resident #1, the resident?s bathroom (located in room 236) did not have hot water coming out of the hot water spigot. When asked how long it had been inoperable, Resident #1 stated, ?A while? but could not specify further. 2. Staff #3 and Licensing Inspector observed during the tour that the hot water spigot in room 236 was not working.
Plan of Correction:	1.Resident #1 has hot water coming out of the spicket. 2.A review of all resident?s rooms to be conducted by the Administrator and Maintenance Director to ensure residents have hot water coming out of the spicket. 3.Administrator/designee has educated the maintenance director to ensure the importance of all residents having hot water coming out of their spicket. The Maintenance director has also been educated on ensuring that all empty resident designated rooms hot water coming out of their spicket for any new admissions or transfers. 4.The administrator/designee to conduct audits of residents/resident designated rooms having hot water coming out of their spicket. Quality monitoring to be conducted monthly X 3 months and as needed thereafter. Findings to be reported to QAPI committee monthly and updated as indicated. Quality monitoring schedule modified based on findings.
Standard #:	22VAC40-73-960-B
Description:	Based on observation and interview with staff, the facility failed to ensure the fire and emergency evacuation drawing showed primary and secondary escape routes, areas of refuge, and assembly areas. Evidence: 1. The posted fire and emergency evacuation drawing as well as additional drawing provided by Staff #1 did not show the primary and secondary escape routes, areas of refuge, and assembly areas.
Plan of Correction:	1. The fire and emergency evacuation drawing now shows primary and secondary escape routes, areas of refuge, and assembly areas. 2. A review of the entire facility floor plans have been reviewed. 3. The Administrator has been educated by the Director of Operations on the importance of keeping the fire and emergency evacuation drawings up to date for the facility. 4. The Administrator/designee to conduct audits to ensure the fire and emergency evacuation drawing shows primary and secondary escape routes, areas of refuge and assembly areas. Quality monitoring to be conducted monthly X 3 months and as needed thereafter. Findings to be reported to QAPI committee monthly and updated as indicated. Quality monitoring schedule modified based on findings.