VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Dogwood Crossing Senior Living And Memory Care
130 Deer Ridge Trail
Tazewell, VA 24651
(276) 385-7150

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: June 13, 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 06/13/2022 9:45am-2:45pm the licensing inspector was on-site at the facility for each day of the inspection: The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Crystal B. Mullins Licensing Inspector at (276) 608-1067 or by email at name@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure that the individualized service plan (ISP) included a description of identified needs based upon the uniform assessment instrument (UAI) and other sources and that the ISP included a written description of who will provide services and when and where services will be provided. EVIDENCE: 1. The UAI for resident 7, dated 06/02/2022 stated that the resident requires the supervision of staff when bathing, and the ISP for resident 7, dated 06/02/2022, indicated that the resident requires the assistance of staff for bathing but did not indicate what type of assistance that staff would provide. 2. The ISP for resident 7, dated 06/02/2022, indicated that the resident has home health services by MSA Home Health for physical, emotional, and spiritual well-being; however, the ISP did not indicate specifically what services that home health would be providing to meet those needs.
Plan of Correction:	Facility Administrator and RCD will review all UAIs and ISPs for completeness, correctness, and that the UAI and ISP matches. [sic]
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to ensure that all information required by standards shall be included and documented on the Medication Administration Record (MAR). EVIDENCE: 1. Resident #1 is prescribed Health Shakes, drink one can with each meal. This treatment is listed on the MAR for June 2022. On June 3 and June 8 there was no initials of the direct care staff member that administered the medication.
Plan of Correction:	Facility Administrator and RCD to instructed RMA's to follow administering supplements per physician's orders and order time. [sic]
Standard #:	22VAC40-73-680-K
Description:	Based on observations made during the review of resident records, the facility failed to ensure the use of as needed (PRN) medications administered by medication aides have obtained from the resident's physician or other prescriber a detailed medication order specifying the symptoms that indicate the use of the medication, exact dosage, the exact time frames the mediation is to be given in a 24 hour period, and directions as to what to do if symptoms persist. EVIDENCE: 1. Resident # 10 has an order for Narcan 4mg/actuation nasal spray, spray one spray into one nostril as directed as needed to use in case of overdose of pain medication. May repeat in alternate nostril after 2-3 minutes, if needed.
Plan of Correction:	Facility Administrator called to attain a discontinued order during inspection.. [sic]
Standard #:	22VAC40-73-690-A
Description:	Based on resident record review, the facility failed to have the medication review completed every six months for one resident. EVIDNECE: 1. Resident #3 was admitted to the facility on 02/02/2018. According to Staff #5. Resident #3 has not had a medication review within the last six month time period.
Plan of Correction:	Facility Administrator and RCD will review orders to make sure that all Pharmacy reviews have been received back from physicians. [sic]