VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Fork Mountain Adult Home
2925 Fork Mountain Road
Rocky mount, VA 24151
(540) 483-8800

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: May 12, 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 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 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/12/2022, 9:12 am to 3:15 pm, with two inspectors. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 22 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: A meal, medication pass. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Susan Mallory, Licensing Inspector at (540) 309-3043 or by email at susan.mallory@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-50-B
Description:	Based on resident record review, the facility failed to ensure that the disclosure statement contained all required components. EVIDENCE: 1. The ?Assisted Living Facility Disclosure Statement? in the record for resident 1, admitted on 04/28/2022, did not contain documentation on whether or not the facility has an on-site emergency electrical power source for the provision of electricity during an interruption of the normal electric power supply.
Plan of Correction:	The facility updated the Disclosure Statement to include the on-site emergency electrical power source. It was discussed at the Resident Council Meeting on 5-17-22.
Standard #:	22VAC40-73-325-B
Description:	Based on resident record review and staff interview, the facility failed to ensure fall risk ratings were reviewed and updated at least annually, when the condition of a resident changes and after a fall. EVIDENCE: 1. The record for resident 2 contained documentation that the last fall risk rating completed for the resident was on 01/26/2020. Interview with staff 4 confirmed this was accurate. 2. The record for resident 3 included ?nurses notes? from facility staff that the resident fell on the following dates: 07/07/2021, 08/05/2021, 08/11/2021, 09/01/2021, 09/12/2021, 10/21/2021, 12/26/2021 and 04/01/2021. The record for resident 3 contained documentation that the last fall risk rating completed for the resident was on 02/06/2020. Interview with staff 4 confirmed this was accurate. 3. The record for resident 4 included ?nurses notes? from facility staff that the resident fell on the following dates: 02/26/2022 and 05/11/2022. The record for resident 4 contained documentation that the last fall risk rating completed for the resident was on 10/21/2021. Interview with staff 4 confirmed this was accurate.
Plan of Correction:	The administrator will review & update the fall risk ratings annually & when the condition of a resident changes after a fall.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review and staff interview, the facility failed to ensure the uniform assessment instrument (UAI) was completed as required. EVIDENCE: 1. The Private Pay UAI for resident 3, dated 02/06/2022, indicated that the resident needs mechanical help only with walking and mobility. The individualized service plan (ISP) for the resident, dated 02/06/2022, indicated that the resident will be assisted while walking with rollator since she sometimes gets off balance and resident will use rollator with two man assist when walking because she is sometimes unstable on feet. Interview with staff 4 revealed that the ISP is correct for both walking and mobility and that the UAI is incorrect.
Plan of Correction:	The UAI has been corrected to reflect mechanical & human help which is what the ISP states.
Standard #:	22VAC40-73-440-F
Description:	Based on resident record review and interview, the facility failed to obtain a uniform assessment instrument (UAI) within 90 days prior to admission. EVIDENCE: 1. Resident 5 moved in 4/5/2022 and the UAI was done on 11/16/2021. Staff 4 stated in an interview that she notified the local DSS a more current one was needed, but it was never done.
Plan of Correction:	We have contacted DSS multiple times to complete an updated UAI. Moving forward no resident will be accepted into the facility without a current UAI.
Standard #:	22VAC40-73-450-A
Description:	Based on resident record review and staff interview, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care was developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. EVIDENCE: 1. Resident 1 was admitted to the facility on 04/28/2022. On the day of the on-site renewal inspection, 05/12/2022, interview with staff 4 revealed that there was no preliminary plan of care or individualized service plan (ISP) that had been completed for the resident.
Plan of Correction:	The UAI was completed on 4/28/22 which was the day of admission, however it was located in the nurses office w/the ISP that was being completed for resident 1.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure the individualized service plan (ISP) contained all required components. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 2, dated 07/20/2021, indicated that the resident?s medications are administered/monitored by lay person. The ISP for the resident, dated 07/20/2021, did not include this identified need. 2. The UAI for resident 2 also indicated that for mobility the resident is ?confined does not move about?, cannot walk and cannot climb stairs. Interview with staff also identified that the resident is non-ambulatory due to being bedbound. These aforementioned identified needs are not indicated on the resident?s ISP dated 07/20/2021.
Plan of Correction:	The ISP has been updated to match the UAI for medication administration. The UAI states mobility for this res. is not performed. The ISP per request now shows res. is bed bound.
Standard #:	22VAC40-73-450-D
Description:	Based on resident record review and staff interview, the facility failed to ensure when hospice care is provided to a resident the services provided by each the hospice organization and the facility are included on the individualized service plan (ISP). EVIDENCE: 1. Interview with staff 4 revealed that residents 3 and 4 are receiving hospice services. The ISP for resident 3, dated 02/06/2022, and resident 4, dated 10/21/2021, did not include that the residents are receiving hospice services.
Plan of Correction:	The ISP's have been updated to reflect hospice care for res. #3, #4 & #6. The ISP for Res. 3 & 4 has been updated to show they are receiving Hospice Care.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the resident or his legal representative. EVIDENCE: 1. The ISP for resident 2, dated 07/20/2021, had not been signed by the resident or his legal representative.
Plan of Correction:	The ISP for Res. 2 has been signed by legal representative.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and staff interview, the facility failed to update an individualized service plan (ISP) as needed for a significant change of a resident?s condition. EVIDENCE: 1. Interview with staff 4 revealed that the resident is on a pureed diet. The ISP for resident 4, dated 10/21/2021, did not contain documentation of this identified need.
Plan of Correction:	The ISP for Res. 3 has been updated to reflect res. is on a pureed diet & it would have been observed by the inspector on the day of inspection.
Standard #:	22VAC40-73-620-A
Description:	Based on interview, the facility failed to obtain oversight of special diets by a dietitian or nutritionist at least every six months. EVIDENCE: 1. Resident 2 is on a special diet (pureed) and in an interview, staff 4 stated she has not been able to have a dietitian or nutritionist do an oversight since before COVID.
Plan of Correction:	The facility has reached out to a number of dieticians to complete an oversight w/ no success.
Standard #:	22VAC40-73-650-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that no medication, medical procedure or treatment was started, changed or discontinued without a valid order from a physician or other prescriber and includes prescription, over-the-counter, and sample medications. EVIDENCE: 1. The ?Report of Resident Physical Examination? for resident 1, dated 04/28/2022, included a signed physician?s order for the resident to have Bepreve eyes drops one drop to eye two times a day and Restasis eye drops one drop to each eye two times a day; however, the facility is not administering these eye drops to the resident and there is no physician?s order discontinuing the aforementioned eye drops. Interview with staff 4 confirmed this was accurate. 2. The record for resident 4 contained a hospitalist discharge summary, dated 03/09/2022, discontinuing the resident?s prescribed Hydrochlorothiazide. The March 2022 medication administration record (MAR) for the resident indicates that the aforementioned medication was discontinued by staff on 03/09/2022 when the resident returned from the hospital; however, the April 2022 MAR for the resident indicates that the resident was administered Hydrochlorothiazide starting on 04/01/2022 until the present. The record for the resident did not contain a valid order from a physician or other prescriber for the resident to be administered this medication effective 04/01/2022.
Plan of Correction:	Family states res. has not used eye drops in years & we received an order from hospital to discontinue eye drops. Res. 1 will be under Care More eff. 6-1-22 & we will receive all new orders for her meds at that time. Pharmacy has discontinued Hydrochlorothiazide from Res. 4 MAR.
Standard #:	22VAC40-73-650-E
Description:	Based on resident record review, the facility failed to have an order for a medication in a resident?s file. EVIDENCE: 1. The LI observed resident 7 being administered Tylenol (acetaminophen) 325 mg, two by mouth three times a day, and the resident?s chart did not have an order for it.
Plan of Correction:	The resident's chart contained an order for the Tylenol 325 mg 2 tabs po tid. It is also included on the MAR.
Standard #:	22VAC40-73-660-A-7
Description:	Based on observation, the facility failed to ensure that dedicated medical equipment was labeled for the resident. EVIDENCE: 1. A glucometer identified as belonging to resident 4 was not marked with the resident?s name.
Plan of Correction:	The name was placed on the glucometer the day of inspection.
Standard #:	22VAC40-73-680-E
Description:	Based on resident record review and observation, the facility failed to ensure treatments ordered by a physician or other prescriber were provided according to his instructions. EVIDENCE: 1. The record for resident 2 contained a physician?s order, dated 12/14/2021, for ?Compression Stockings on am off pm?. 2. Based on observation by one licensing inspector (LI) at approximately 10:32AM, the resident was not wearing the prescribed compression stockings. Also, there was no documentation maintained in the resident?s record that staff have been applying and removing the compression stockings daily.
Plan of Correction:	The order for compression stockings was discontinued dur to resident being bed bound.
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to be maintained in good repair and kept clean. EVIDENCE: 1. Floor tiles between the living room and hall, and in the dining room had cracks and some missing pieces in them, causing a possible trip hazard.
Plan of Correction:	The floor tiles were replaced.
Standard #:	22VAC40-73-925-C
Description:	Based on observation, the facility failed to prevent residents from sharing bar soap. EVIDENCE: 1. The bathroom in suite 9 is used by three residents, and only bar soap was available at the sink
Plan of Correction:	The bar soap was removed & replaced with pump soap.