VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Golden Years Assisted Living Facility, Inc.
40 Hunt Club Boulevard
Hampton, VA 23666
(757) 825-2425

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: June 23, 2022 , June 24, 2022 , June 28, 2022 , July 5, 2022 , July 11, 2022 and July 12, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 222VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal An unannounced on-site renewal inspection was conducted on 6-23-22 (Ar 7:50 a.m./dep 5:35 p.m). The facility census was 86, a tour of the facility was conducted, breakfast and dinner meal observed (the dining room is not sufficient for all residents, the facility does not have multiple seating times). Emergency preparedness and supplies reviewed, staff and resident records reviewed, staff and resident interviews conducted, medication pass observation conducted, water temperature observed, fire and health inspections reviewed (not current) and other protocol documents reviewed. The Acknowledgement of Inspection form was sent via email to the Administrator following the on-site inspection and following all documents requested and received (6-24-22, 6-28-22 and 7-5-22. Acknowledgement form also sent following preliminary exit review of violations on 7-11-22. 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 Willie Barnes Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on observation and staff interviewed, the facility failed to ensure blood glucose monitoring practices that are consistent with CDC recommendations were utilized during blood glucose check for a resident. Evidence: 1. On 6-23-22 at 08:03, during the medication pass observation with staff #4, resident #4?s blood glucose was observed taken using a glucometer labeled ?HM?. Staff stated it was the house glucometer that was used when a resident did not have a glucometer. The glucometer was removed from a container on the medication cart and placed on top of the medication cart. The staff did not clean the glucometer prior to and after the finger stick. 2. Staff #1 stated the staff was new and may need to be retrained.
Plan of Correction:	RCC will ensure that a resident individual glucometers will be labeled. Additional infection control for medication aides has been scheduled for Aug.9th.
Standard #:	22VAC40-73-290-A
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure the written work schedule include the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time. Evidence: 1. On 6-23-22, the staff schedules provided did not include all required information. The business office schedule, the May 2022 housekeeping/laundry schedule, the June 2022 kitchen morning and evening schedule, the June 2022 CNA (7-3), (3-11), and 11-7 schedule, June 2022 Med-tech (7-3), (3-11), and 11-7 schedule noted first name only of staff. The job classification of the business office staff, CNA and kitchen staff were not documented on the schedule. 2. The schedule also did not indicate who was in charge at any given time.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-B
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it for four of seven residents. Evidence: 1. On 6-23-22, resident #5?s risk assessment for tuberculosis (TB) in the record was dated 8-5-19, resident?s date of admit noted as 5-3-19. Resident #1?s TB was dated 6-17-21, resident?s date of admit was noted as 11-1-18. Resident #4?s TB was dated 6-18-21, resident?s date of admit was noted as 1-25-19. Resident #6?s TB was dated 6-17-21, resident?s date of admit was noted as 1-6-20. 2. Staff #2 acknowledged the TB?s were not completed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-H
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure an annual reassessment, using the UAI, shall be utilized to determine whether a resident?s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: 1. Resident #4?s uniformed assessment instrument (UAI) in the record was last dated 4-6-20. The resident?s date of admit was noted as 1-25-19. 2. Staff #1 and #2 acknowledged the aforementioned resident did not have an annual reassessment using the UAI to determine continue placement in the facility.
Plan of Correction:	Administrator's assistant will continue to request UAI's from APS and CSB 30 days prior to expiration date to ensure UAI's are done in a timely manner.
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s individualized service plan (ISP) included all assessed needs for six of seven residents? records. Evidence: 1. Resident #2?s uniformed assessment instrument (UAI) dated 10-9-21 documented toileting need as human help/physical assistance, walking as mechanical help with a cane, mobility assessed as mechanical help/supervision with cane, and money management by POA. The ISP with ending/review date of 11-11-22 did not include these assessed needs. 2. Resident #3?s UAI dated 9-10-21 (9-29-21) documented dressing need as human help/physical assistance, incontinent of bowel and bladder, stairclimbing not performed, and resident assessed as disoriented some spheres all time for ?Time?, short-term memory lost and judgement issues. The resident?s signed physician?s order dated 2-9-22 documented resident is allergic to Tetracylines and Fluarix. These assessed needs and allergy information were not documented on resident?s ISP dated10-5-21. 3. Resident #4?s ISP dated 9-23-21 did not document resident?s money management by a local agency and the change to the facility as the resident?s money representative. 4. Resident #5?s need for the use of Oxygen was not documented on the 4-29-22 ISP. 5. Resident #6?s ISP dated 1-6-22 did not include resident?s tomato allergy, physician document dated 2-9-22. 6. Resident #7?s UAI dated 6-7-21 documented stairclimbing not performed, the ISP dated 10-5-21 did not include stairclimbing. 7. Staff #2 acknowledged the aforementioned residents? ISPs did not include all assessed needs.
Plan of Correction:	Administrator and Administrator's assistant will review, document and update ISP's according to UAI. Facility pharmacy nurse will also oversight each plan.
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service was updated as needed as the condition of the resident changes for two of seven residents. Evidence: 1. Resident #6?s record documented skilled nursing for wound care services 1-13-22; physical therapy services 1-7-22 thru 2-18-22. The record also included physician?s order dated 4-18-22 for occupational therapy (OT) and physical therapy (PT) services for unsteady gait BLE metatarsal amputees; additional physician notes dated 3-4-22 and 4-15-22. Staff #1 and 2 stated resident had toes amputated and did not need special shoes and family member took care of resident's medical appointments. Resident was observed wearing regular sneakers. 2.Resident #7?s ISP dated 10-5-21 did not document wound care needs, venous ulcer LLE, resident receiving outpatient services from wound care clinic, document in record dated 9-15-21 and 10-15-21. Staff #6 stated resident receives skilled nursing wound care services from a home health provider. The record did not include documentation of home health visits. The record also included physical order dated 4-25-22 for consult PT/OT evaluation and treat; frequent falls. 3. Staff #2 acknowledged the aforementioned resident?s ISP reviewed on 6-23-22 were not updated to include resident change in condition and services received. Records were updated after reviewed by inspector on 6-23-22.
Plan of Correction:	Administrator's assistant is working with Home Health agency to detail their services thru contract to chart in designated area of residents file. Home Health agency to communicate with RCC and Administrator to keep ISP's current.
Standard #:	22VAC40-73-470-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure, either directly or indirectly, that the health care service needs of residents are met for a resident. Evidence: 1. On 6-23-22, resident #2?s physical examination dated 11-1-21 documented physician?s recommendation for home health services. The record did not contain documentation of resident?s home health services. 2. Staff #2 acknowledged the aforementioned resident?s record did not include documentation of completion of the physician?s recommendation for home health services.
Plan of Correction:	To ensure physician's recommendation for Home Health documented on History & Physical. Admission coordinator will be responsible for scheduling Home Health on Admission Day.
Standard #:	22VAC40-73-580-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure when a portion of the assisted living facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as evidence by an initial and subsequent annual report from the Virginia Department of Health. The report shall be retained at the facility for a period of at least two years. Evidence: 1. On 6-23-22, the health inspection document provided to the inspector was dated 6-21-21. 2. Staff #1 acknowledged not having a current health inspection.
Plan of Correction:	The Director of operations will be responsible for scheduling Health Dept. inspections 30 days prior to expiration date to ensure inspection is completed prior to expiration.
Standard #:	22VAC40-73-610-E
Description:	Based on staff interviewed, the facility failed to ensure a copy of a diet manual containing acceptable practices and standards for nutrition was kept current and readily available to personnel responsible for food preparation. Evidence: 1. On 6-23-22 during a tour of the kitchen with staff #5 and #7, when asked to see the facility?s nutrition manual, staff did not have a copy. 2. Staff #5 and #7 acknowledged the facility did not have a copy of a diet manual in the kitchen.
Plan of Correction:	Facility food manager will be responsible for keeping diet manual current and accessible to dietary staff. Manual has been placed in the kitchen.
Standard #:	22VAC40-73-860-G
Description:	Based on observation and staff interviewed, the facility failed to ensure the hot water at taps available to residents was maintained within a range of 105 degrees Fahrenheit (F). to 120 degrees F. Evidence: 1. On 6-23-22 during a tour of the facility with staff #5 and #8, water temperatures were conducted in three rooms. The water temperature in room #37 was 133.0 degrees F. 2. Staff #5 and #8 acknowledged the water temperature did not meet the required temperature range.
Plan of Correction:	Hot water tank has been adjusted for appropriate water temperature. Maintenance will be responsible for charting weekly water temperatures, make necessary adjustments. Paperwork will be reviewed monthly by the Administrator and Director of Operations.
Standard #:	22VAC40-73-940-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the facility complied with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Reports of the inspections shall be retained at the facility for at least two years. Evidence: 1. On 6-23-22, the fire inspection document provided was dated 5-13-21. 2. Staff #1 acknowledged the facility did not have a current fire inspection.
Plan of Correction:	Director of Operations will continue to schedule fire inspections 30 days prior to expiration to ensure inspection is completed prior to expiration.
Standard #:	22VAC40-90-40-B
Description:	Based on document received and staff interviewed, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee. Evidence: 1. On 6-23-22, 6-24-22, 6-28-22, 7-5-22 and 7-12-22, the facility provided information for new hires. There were seven staff members whose criminal history report was not obtained on or prior to the 30the day of employment. Staff date of hire range from 3-30-21 to 4-13-22. 2. Staff #1 stated ?needing to grab up staff? when possible because of staffing concerns.
Plan of Correction:	RCC will indicate on schedule, new hires will be shadowed by another staff member with CRC on file until new hire CRC comes in.