VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Town Creek Assisted Living Facility
393 Front Street
Lovingston, VA 22949
(434) 263-4313

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

Inspection Date: June 1, 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 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 of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/01/2022. 9am until 3pm 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: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 15 Number of staff records reviewed: 7 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standards or law, and violations 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-1
Description:	Based on audits of the facility medication carts and document review, the facility failed to implement their infection control policy in regards to assisted blood glucose monitoring. EVIDENCE: 1. The facility infection control policy has documentation that glucometers are assigned to individual residents, labeled appropriately and are to be used only by that resident. 2. The glucometers in the bags for residents 1, 4 and 14 were not labeled with the residents name on the day of inspection. 3. An unlabeled glucometer was noted lying out in the top right side drawer of the facility C medication cart.
Plan of Correction:	Blood Glucose monitors where label on 6-1-22. Staff was also educated on label the monitor as well as the cases.
Standard #:	22VAC40-73-270-1
Description:	Based on staff record review and staff interview, the facility failed to ensure direct care staff were trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. EVIDENCE: 1. The records for staff 1, date of hire 01/11/2021, and staff 3, date of hire 03/30/2021, did not contain documentation of training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. Interview with staff 2 indicated that the facility does have in care residents that have a history of aggressive behaviors.
Plan of Correction:	QMHP will provide aggressive training with demonstrations within 7 days of hire for all new hires starting 6-1-22.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure the physical examination contained all required components. EVIDENCE: 1. The record for resident 1 contained a physical examination, dated 06/15/2021, that indicated the resident has allergies to Nonsteroidal Anti-inflammatory agents, Cephalosporins, Penicillin G, and Aspirin; however, the physical examination did not include a description of the resident?s reactions
Plan of Correction:	Administrator and Program manger will ensure each H&P has a reaction listed for each allergy before allowing the resident to be admitted into the facility starting 6-1-22.
Standard #:	22VAC40-73-350-B
Description:	Based on resident record review, the facility failed to ascertain, prior to admission, whether a resident is a registered sex offender. EVIDENCE: 1. The record for resident 1, date of admission 06/15/2021, contained documentation that a sex offender registry search was not completed for the resident until 06/23/2021.
Plan of Correction:	Sex offender search will be completed when a referral is made to ensure it is completed prior to their arrival. Starting 6-1-22.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that the uniform assessment instrument (UAI) for residents was completed as required. EVIDENCE: 1. The public pay UAI for resident 3, dated 08/01/2021, and resident 7, dated 02/01/2022, did not include required documentation of how residents 3 and 7 take their medications or the orientation status and behavior pattern for residents 3 and 7. 2. The public pay UAI for resident 5, dated 04/11/2022, did not indicate whether the resident needs assistance with eating/feeding, housekeeping and laundry.
Plan of Correction:	UAI?s where updated for all residents 6-3-22. Case manager has been instructed on how to properly complete UAI?s and will work with the Admin team at town creek to ensure that they are completed accurately.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to update resident individualized services plans (ISPs) when a change occurred. EVIDENCE: 1. The history and physical dated 05/03/2022 in the record for resident 4 has documentation that the resident is prescribed a low carb diet. The comprehensive ISP dated 05/12/2022 does not reflect this identified need.
Plan of Correction:	ISP was updated 6-1-22 to reflect the correct diet for the resident.
Standard #:	22VAC40-73-490-A
Description:	Based on document review and staff interview, the facility failed to ensure health care oversight by a licensed health care professional, practicing within the scope of his profession, at least every three months for residents who meet the criteria for assisted living care. EVIDENCE: 1. Documentation indicated that the last record of on-site health care oversight was conducted for residents who meet the criteria for assisted living care from 08/01/2021 through 10/31/2021. Interview with staff 2 confirmed this was accurate meaning that health care oversight has not been conducted at least every three months.
Plan of Correction:	HCO was completed by pharmacy nurse. HCO will be conducted ever three months and has been placed on a scheduled for tracking.
Standard #:	22VAC40-73-610-D
Description:	Based on resident record review, document review and interviews with staff, the facility failed to ensure that special diets prescribed by a physician were prepared and served according to physician orders. EVIDENCE: 1. The history and physical dated 05/03/2022 in the record for resident 4 has documentation that the resident is prescribed a low carb diet. 2. Observations of the facility special diet list located in the facility kitchen shows that resident 4?s prescribed diet is not included on the special diet list. 3. An interview conducted with staff 6 expressed that they were not aware of resident 4?s special diet and that resident 4 has been receiving a regular diet.
Plan of Correction:	Diet list was update 6-1-22 to reflect the correct diet. Diet orders will be communicated to kitchen manager upon receiving the order and then will be placed on the diet list for kitchen to review.
Standard #:	22VAC40-73-640-A
Description:	Based on audits of the facility medication carts and document review, the facility failed to implement their medication management plan in regards to outdated medications. EVIDENCE: 1. The facility medication management plan has documentation that any insulin more than 28 days old, is to be disposed of and a new vial of insulin must be ordered immediately. Do not give expired insulin. 2. An open Lantus Solostar pen and an open Humalog Kwikpen were observed in the medication cart for resident 15. Neither pen had an opened or discard date to determine if they were past the 28 days from opening.
Plan of Correction:	old pens disposed of and new pens used and dated 6-1-22. Training on dating pens in being held 6/8/22
Standard #:	22VAC40-73-680-M
Description:	Based on observation during medication cart audit, resident record review and staff interview, the facility failed to ensure medications ordered for PRN (as needed) administration were available at the facility. EVIDENCE: 1. The May and June 2022 medication administration record (MAR) for resident 9 contained documentation that the resident has a current order for PRN Hydrocortisone 1% cream and PRN Lidocaine-HC 3-0.5% cream. Interview with staff 3 confirmed that the aforementioned creams were not available on-site during the inspection. 2. The June 2022 MAR for resident 11 had physician orders for Eucerin Plus Intensive Repair, apply to affected areas 3 times a day as needed for itching, Muprocin 2% ointment, apply to abrasion topically 2 times a day until healed and Sarna Sensitive 1% lotion, apply as often as needed for itching. Interview with staff 3 confirmed that the aforementioned creams were not available on-site during the inspection.
Plan of Correction:	All Creams ordered and delivered 6-2-22.