VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Fort Shelby Manor
200 Solar Street
Bristol, VA 24201
(276) 669-3562

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: June 6, 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:

ype of inspection: Monitoring 6/6/22 Start: 9:45am Stop: 4:30pm 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. Number of residents present at the facility at the beginning of the inspection: 39 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 16 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: 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 Crystal B. Mullins, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on observations made during the medication cart audit, the facility failed to follow proper procedures of the infection prevention measures. EVIDENCE: 1. The glucometer bag for Resident #12 was labeled, but the glucometer itself was not. 2.The glucometer bag for Resident #14 was labeled, but the glucometer inside of the bag was labeled with another resident?s name.
Plan of Correction:	Each glucometer will be properly labeled with the correct Residents name and each bag will be labeled with the Resident's name. [sic]
Standard #:	22VAC40-73-290-B
Description:	Based on observations made during the tour of the building, the facility failed to post the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public. EVIDENCE: 1. On the date of the inspection (6/6/22), the LI did not observe the posting of the on-site person in charge.
Plan of Correction:	A list will be kept posted in each building showing the on-site person in charge, as required by DSS. [sic]
Standard #:	22VAC40-73-320-A
Description:	Based on observations made during the review of resident records, the facility failed to have all required information documented by an independent physician on the physical examination report within 30 days preceding admission to an assisted living facility for two residents. EVIDNECE: 1. Resident #7 has a physical exam documented on 5/18/2021. The physician listed allergies as codeine, tape, Seroquel, Depakote, and penicillin. There were no reactions documented for these allergies. 2. Resident #3 has a physical exam documented on 11/30/202. The physician listed Haloperidol, Benadryl, Phenergan; Thorazine, and Penicillin as allergies. There were no reactions documented for these listed allergies.
Plan of Correction:	Administrator will see that any allergies noted on physical exam of all residents will have reactions also noted. Residents reactions have been noted in files. [sic]
Standard #:	22VAC40-73-380-A
Description:	Based on observations made during the review of resident records, the facility failed to obtain all information required by standards on the personal and social information sheet prior to or at the time of admission to an assisted living facility for one resident. EVIDENCE: 1. Resident #7 was admitted to the facility on 6/3/21. The following pieces of information were left blank on the personal and social data for Resident #3: interest/hobby, clergy, personal dentist, designated contact person, next of kin, local department of social services, other agency, the information on mental health was marked yes, but left blank and the current behavioral and social functioning section regarding strengths and problems was also left blank.
Plan of Correction:	In the future, Administrator will make sure that all information is noted on admission forms at the time of admission information that was left off forms has been corrected. [sic]
Standard #:	22VAC40-73-680-K
Description:	Based on observations made during the noon medication pass, the facility failed to have a detailed medication order to include symptoms that indicate the use of the medication, the exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist if a medication aide administers a PRN (as needed) medication. EVIDENCE: 1. Resident #16 has a physician?s order for Narcan 4mg to be administered into nostrils as needed, follow package instructions for opioid emergencies.
Plan of Correction:	Administrator contacted MD office requesting a new order with the required 4 points per DSS Standards. 1. symptoms for which med is to be given. 2. exact dose, 3. exact time in 24 hr period., 4 what to do if symptoms persist. Administrator has obtained training material on Naloxone with signs/symptoms of opioid emergencies from the Pharmacy and placed in each MAR. In the future Administrator will make sure all orders are specific to DSS standards. [sic]
Standard #:	22VAC40-73-680-M
Description:	Based on observations made during the audit of the medication cart, the facility failed to have medications ordered for PRN (as needed) administration available at the facility. EVIDNECE: 1. Resident #13 had the following medications listed on the May and June 2022 MAR (Medication Administration Record) as well as physician?s orders; yet these medications were not available for Resident #13 for PRN use: 1. Acetaminophen 325 mg tablet, take one tablet by mouth every six hours as needed for pain or fever. 2. Fluticasone Prop 50 MCG spray, use one spray in each nostril twice daily as needed for allergies.
Plan of Correction:	Administrator and Med Techs will make sure all PRN medications are monitored on a daily basis to see that they are on the floor and available for the Residents as ordered by their physicians. Missing medications have been ordered and replaced. [sic]
Standard #:	22VAC40-73-690-F
Description:	Based on the audit of the medication review, the facility failed to have the findings of the medication review in writing, signed and dated by the health care professional and the identification of each resident?s medications that were reviewed. EVIDENCE: 1. The medication review dated 6/22/2021 and 12/21/2021 had ?COVID-19, No actual visit? documented on the one piece of paper that was given to the administrator.
Plan of Correction:	Pharmacy Oversight was done on 06/13/22 for each individual resident with a signed sheet for their file. The Pharmacy will do oversight for Residents every six months as required. [sic]
Standard #:	22VAC40-73-870-B
Description:	Based on observations made during the tour of the building, the facility failed to make sure all building are well-ventilated and free from foul, stale, and musty odors: EVIDENCE: 1. The common bathroom on the second floor of the lady?s house had a strong urine smell.
Plan of Correction:	Staff will monitor bathrooms for odors on a regular schedule to make sure they are kept clean or don't have any problems. Office has purchased air cleaning machine to help with these problems. [sic]
Standard #:	22VAC40-73-870-C
Description:	Based on observations made during the tour of the building, the facility failed to have adequate provision for the collection and disposal of garbage. EVIDENCE: 1. Room #1 in the men?s house had a small white trashcan near the entrance door that was found to be heaped up and running over with trash.
Plan of Correction:	The Administrator will monitor the trash situation on a daily basis to make sure that there is adequate provision for collection and disposal of trash and garbage. [sic]
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during the tour of the building, the facility failed to keep clean and in good repair all furnishings, fixtures, equipment except those owned by a resident. EVIDENCE: 1. The LI observed a large swarm of gnats at the water pitcher/coffee pot stand at in the men?s house. 2. The top of the bookcase/water/coffee station was observed to be worn and sagging in the middle. The white area was discolored and appeared brown. 3. Room #1 in the men?s house had a chest of drawers in the middle of the room with the top drawer opened. There was food particles and partially opened cups of pancake syrup observed. On the top of the same chest, there was a white napkin/tissue, salt packets which had been opened and other food items open and exposed. 4. Room #1 in the men?s house had a dresser between two beds. On the top of the dresser there were three packets of powered coffee creamer found to be open and scattered about the surface.
Plan of Correction:	The Administrator will monitor the rooms on a daily basis to make sure that they are kept clean and in good repair. The furnishing holding the coffee pot has been replaced and sugar for coffee is being kept in the kitchen to help prevent gnats. The administrator will see that the rooms are kept clean and free of clutter causing trash. [sic]
Standard #:	22VAC40-73-980-G
Description:	Based on observations made during the tour of the building, the facility failed to have available at least 48 hour supply of emergency drinking water on site. EVIDENCE: 1. The facility had a total of 36 gallons of emergency drinking water on site on the date of the inspection. The recommendation is one gallon per resident and staff per 24 hour period.
Plan of Correction:	Administrator will see that we keep the required amount of drinking water at the facility and available for Residents and staff. [sic]