VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Elance at Tuckahoe
567 N. Parham Road
Henrico, VA 23229
(804) 554-3939

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: June 14, 2022 , June 15, 2022 , July 8, 2022 and July 11, 2022

Complaint Related: Yes

Comments:

The inspector was on-site at the facility: 06/14/2022 between the approximate time of 9:30a.m until 6:10p.m 06/15/2022: between the approximate time of 10:00a.m until 3:54p.m 07/08/2022: between the approximate time of 3:24p.m until 6:36p.m 07/11/2022: between the approximate time of 11:06a.m until 5:16p.m The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/13/2022. Number of residents present at the facility at the beginning of the inspection: 34 The licensing inspector completed a tour of the safe and secure environment that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 5 Number of interviews conducted with residents: Number of interviews conducted with staff: 9 The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-130-A
Complaint related:	Yes
Description:	Based on interviews conducted and the review of facility records the facility failed to make a report as mandated under ? 63.2-1606 of the Code of Virginia of suspected abuse, neglect, or exploitation of residents. Evidence: Resident #1:Documented date of admission 02/23/2022 The anonymous complainant reported that approximately the last week of April 2022 a report was made that a direct care agency staff allegedly recorded resident #1 while the resident was on the toilet and uploaded the video recording to social media. The complainant further reported that facility staff #5 in her presence facility staff informed the facility Administrator of the incident. On 05/20/2022 during a telephone interview with the facility Administrator the inspector offered technical assistance to the facility Administrator regarding mandated reporting to the local Adult Protective Services agency. (APS) 06/14/2022: Responding to the inspector?s inquiry during interviews whether a report had been made to the local APS; the facility Administrator stated that she had not made a report. As a mandated reporter and as specified in ? 63.2-1606 of the Code of Virginia the facility Administrator did not make a report to the local Adult Protective Services department regarding matters giving reason to suspect abuse, neglect, or exploitation of resident #1
Plan of Correction:	FACILITY RESPONSE " The facility will ensure that an investigation into all reports of neglect, abuse or exploitation will occur immediately and will be reported to Adult Protective Services as mandated under ? 63.2-1606. Training will be conducted with facility staff on mandated reporting and abuse, neglect and exploitation. Person Responsible: Executive Director, Director of Health and Wellness."
Standard #:	22VAC40-73-150-D
Complaint related:	Yes
Description:	Based on interviews conducted with the facility Administrator and the Director of Nursing and the review of facility records the administrator failed to report to the Director of the Department of Health Professions information required by and in accordance with ? 54.1-2400.6 of the Code of Virginia regarding any person (i) licensed, certified, or registered by a health regulatory board or (ii) holding a multistate licensure privilege to practice nursing or an applicant for licensure, certification, or registration. Information required to be reported, under specified circumstances includes substance abuse and unethical or fraudulent conduct. Evidence: The anonymous complainant alleges that on 05/13/2022 during the 3-11 shift multiple facility residents on the 3rd floor were not administered their medications and that facility staff #1 signed the MAR electronically indicating that the medications were administered. Interviews conducted with the facility Administrator and facility staff #1 revealed the following: On 05/20/2022 during a telephone interview with the facility Administrator the inspector offered technical assistance to the facility Administrator to clarify issues regarding the need to report the allegations to the Department of Health Professions. 06/14/2022: Facility staff #1-Responding to the inspector?s inquiry during interviews whether she signed the facility?s 05/13/2022 medication administration record (MARs) documenting that multiple residents on the 3rd floor were administered their medications during the 3-11 shift when they in fact were not; facility staff #1 responded by stating ?yes?. When the inspector asked why-facility staff #1did not respond. Later on 06/14/2022: The inspector provided technical assistance to the facility Administrator throughout the day and in the presence of facility staff #1 as well as during the exit interview on 06/14/2022 that a report regarding facility staff #1s? admission regarding medication administration on 05/13/2022 must be reported to the Department of Health Professions. 06/15/2022: Responding to the inspector?s inquiry during interviews whether she had made a report to the Department of Health Professions regarding the 05/13/2022 medication administration allegations-the facility Administrator stated no she had not.
Plan of Correction:	FACILITY RESPONSE "The facility will ensure that reports are made to the the Director of the Department of Health Professions in accordance with ? 54.1-2400.6 of the Code of Virginia. The supervisors of the community have been in-serviced on reporting substance abuse and unethical or fraudulent conduct. Systemically, this training will happen annually for all supervisors. The business office director will audit the supervisor files to ensure documentation is available. The executive director will complete random audits to ensure ongoing success. Person Responsible: Executive Director, Business Office Director"
Standard #:	22VAC40-73-250-D
Complaint related:	No
Description:	Based on the review of facility records the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility and prior to coming in contact with residents submitted the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Staff #4--Documented Start date 04/19/2022 Facility records submitted for the inspector?s review is not documented to identify that facility staff #4 is free of tuberculosis in a communicable form.
Plan of Correction:	FACILITY RESPONSE "All staff will have a risk assessment documenting the absence of tuberculosis in a communicable form on or within seven days of the first day of work. An audit of all current employee files will be completed to ensure compliance. All new hire files will be audited within 3 days of hire to maintain compliance. Person Responsible: Executive Director, Business Office Director"
Standard #:	22VAC40-73-280-A
Complaint related:	Yes
Description:	The assisted living facility failed to ensure that staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with this chapter. Evidence: Resident #3-Documented date of admission 01/20/2022 ' The complainant reported that on 04/02, 03/2022 during the 7-3 shift there were only two direct care staff on the memory care unit and that facility staff # 7 was left alone on the memory care unit when facility staff #6 had to help administer medications to the residents on the assisted level of care program; 2nd and 3rd floors. The facility?s Administrator clarified that the Employee Punch Report document identifies facility direct care staff that were actually paid for the days noted and the Anthology Tuckahoe-Care Staff Assignments document is used to identify the specific staff assignment for the day. Charting for 04/02/2022 during the 7-3 shift- the documents identifies that facility staff #s 6, 7, 8 and 9 were the only direct care staff in the building. Facility staff #s 6 and 7 were assigned to the memory care unit. Facility staff #8 assigned to relieve staff on the memory care unit for breaks. Facility staff # 9 assigned to the 2nd and 3rd floors. ' The complainant alleged that on 05/10/2022 during the 3-11 shift facility staff could not take their lunchbreaks because they had to provide one-on-one supervision to a resident that eloped and or tried to elope. Staffing for 05/10/2022 during the 3-11 shift: Employee Punch Report document identifies facility direct care staff #s 4, 5, 11 and 13. Facility staff #s 4 and 5 were assigned to the memory care unit. Facility staff #11 and two direct care agency staff were assigned to the 2nd and 3rd floors. The staff assignment document identifies facility staff # 12 is assigned to the memory care unit but the Employee Punch Report document does not identify that facility staff #12 worked at the facility on 05/10/2022. The 05/10/2022 staff assignment document does not identify an assignment for facility staff #13 during the 3-11 shift. Facility records noted multiple incidents of the resident #2 being physically aggressive, eloping and or attempts to elope on 05/10/2022. Charting for 05/21/2022 during the 3-11 shift facility staff # 13 documented on the Dayforce Missed Punch document notes ? 0 lunch did all 3 carts!!.? ' Responding to the inspector?s inquiry during interviews on 06/14, 15/2022 whether facility staff # 6 was the only staff that administered medications to facility residents on 05/14/2022 during the 3-11 shift; the Administrator stated yes. The facility did not ensure that appropriate staffing was in place based on the equity level of all facility residents.
Plan of Correction:	FACILITY RESPONSE "The facility is currently staffed at an appropriate level, and will ensure that appropriate staffing is in place based on the acuity levels of all residents in the facility to maintain the physical, mental and psychosocial well-being of each resident. The facility will maintain an accurate as-worked schedule. An inservice was conducted with the direct care team on June 29, 2022 to discuss proper use of the timeclock. Person Responsible: Executive Director, Director of Health and Wellness, Resident Care Coordinator.
Standard #:	22VAC40-73-320-A
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted with the facility Administrator and other facility staff the facility failed to obtain within the 30 days preceding admission, a physical examination by an independent physician. Evidence: #2--Documented date of admission 05/10/2022 Facility records noted that the resident?s physical examination report dated 01/28/2022 was conducted over three months prior to the residents? date of admission.
Plan of Correction:	FACILITY RESPONSE "The physical exam was completed on April 18, 2022; the physician made an error on page one and wrote January 1, 2022. Moving forward, the facility will ensure that all physical exams are dated within the 30 days preceding admission. An inservice will be conducted with the Director of Sales and Marketing to educate on the requirement of 22VAC40-73-320. A+B2. Person Responsible: Executive Director, Director of Health and Wellness, Director of Sales and Marketing
Standard #:	22VAC40-73-325-A
Complaint related:	No
Description:	For residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating shall be completed. Evidence: Resident #3- Documented date of admission 01/20/202 Upon request to review all fall assessments and analysis the facility Administrator submitted the following Fall Assessment Results documents dated 03/30, 31/2022 and 05/10/2022. The facility did not submit for the inspector?s review documentation that a fall risk rating had been conducted within 30 days after the resident was admitted to the facility.
Plan of Correction:	FACILITY RESPONSE "The facility will ensure that a written fall risk rating is completed within 30 days after admission to the facility. An audit of all admissions since June 1 will be completed and all new admissions will be audited 25 days after admission to maintain compliance. Person Responsible: Executive Director, Director of Health and Wellness. "
Standard #:	22VAC40-73-325-B
Complaint related:	Yes
Description:	Based on the review of facility records the facility failed to ensure that the fall risk rating was reviewed and updated under when the condition of the resident changes. Evidence: Resident #3- Documented date of admission 01/20/2022 The resident?s 01/14/2022 physical examination report document does not identify the resident as being at risk for falls. The Progress Notes document notes that the resident had falls on 03/26, 29, 31/2022. The 03/30/2022 Fall Assessment Results document noted that the resident have had 1-2 falls within the last 90 days. Upon request the facility did not submit for the inspector?s review documentation of the fall risk ratings that was conducted regarding the change in the resident?s condition referenced on 03/26,29, 30,31/2022.
Plan of Correction:	FACILITY RESPONSE The Director of Health and Wellness and Executive Director will review progress notes and ensure that a written fall risk rating is completed when a resident experience a change in condition. An audit of all falls since July 1, 2022 will be completed to ensure that a fall risk rating has been done. Person Responsible: Executive Director, Director of Health and Wellness.
Standard #:	22VAC40-73-325-C
Complaint related:	Yes
Description:	Based on the review of facility records the facility failed to ensure that the fall risk analysis was reviewed and updated after a fall. Evidence: Resident #3- Documented date of admission 01/20/2022 The facility?s Progress Notes document only identifies resident falls that occurred on 03/26, 31/2022 and 05/10/2022. Upon request the facility did not submit documentation that analysis of the circumstances of the fall and that interventions were initiated to prevent or reduce the risk of subsequent falls regarding the residents falls
Plan of Correction:	The facility will ensure that a fall risk analysis is reviewed and updated after a fall. Facility staff will be educated on proper documentation. The Director of Health and Wellness will conduct an audit daily with each incident and submit for review to the Executive Director weekly. Person Responsible: Executive Director, Director of Health and Wellness.
Standard #:	22VAC40-73-430-H-1
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that at the time of discharge, the assisted living facility provided to the resident and, as appropriate, his legal representative and designated contact person a dated statement signed by the licensee or administrator that contained all of the required elements and ensured that a copy of the written statement is retained in the resident's record. Evidence: Resident #s 3 and 6 During interviews the facility Administrator and direct care staff informed the inspector that the residents had terminated placement with the facility. Upon request the facility did not submit for the inspector?s review documented evidence that the resident?s legal representative was provided documentation of the reason or reasons for the discharge; the actions taken by the facility to assist the resident in the discharge and relocation process and the date of the actual discharge from the facility and the resident's destination
Plan of Correction:	FACILITY RESPONSE "The Executive Director will ensure that discharge statements are provided to every resident at the time of discharge. An audit of all discharged residents will be conducted to ensure and maintain compliance. Person Responsible: Executive Director, Director of Health and Wellness."
Standard #:	22VAC40-73-450-A
Complaint related:	Yes
Description:	Based on the review of facility records and the interviews conducted the facility Administrator and facility direct care staff the facility failed to ensure that 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. The preliminary plan must be developed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident, and, as appropriate, other individuals noted in subdivision B 1 of this section. The preliminary plan must be identified as such and be signed and dated by the licensee, administrator, or his designee (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: It was revealed during the review of facility records and staff interviews conducted that facility staff #3 developed and or approved the Individualized Service Plans for resident #s 1, 3, 4, 5, and 6. Facility staff #3 does not meet department qualifications to develop ISPs for assisted living facility residents. The ISPs that were submitted for the residents are not identified as the preliminary ISPs and are not documented to identify the participation of the resident and or legal representatives or other individuals that are involved with the resident. The ISPs were not developed on or within seven days prior to the day of admission. #1: Documented date of admission 02/23/2022 ISP dated 02/23/2022 #3-Documented date of admission 01/20/2022: ISP dated 02/21/2022 #4: Documented date of admission 01/28/2022. ISP signed by former facility staff on 02/16/2022 and by facility staff #3 on 02/22/2022 #5: Documented date of admission 01/17/2022. ISP dated 03/16/2022(over two months overdue) #6: ISP dated 02/23/2022 and developed by facility staff #3. #2:Documented date of admission 05/10/2022-The resident?s 05/10/2022 ISP that was developed by facility staff #1 is not documented to identify as the preliminary ISP. The language in the ISPs for resident 1-6 were revealed to be duplicates of the other and not individualized based on the assessed and or reported needs of the residents.
Plan of Correction:	FACILITY RESPONSE "The facility will ensure that on or within seven days prior to the day of admission, a preliminary plan of care will be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. All plans of care will be developed by a staff person with the qualifications specified in subsection B of this section, in conjunction with the resident and, as appropriate, other individuals noted in subdivision B 1 of this section and will be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative. All ISPs will be individualized based on the assessed and/or reported needs of the resident. The Director of Health and Wellness and Executive Director will attend ISP training. An audit of all resident charts will be conducted to ensure that the ISP is in the chart and that all ISPs are signed by the licensee, administrator or his designee, and by the resident or his legal representative. A copy of the signature page of each care plan will be maintained in a secure location. Person(s) Responsible: Director of Health and Wellness and Executive Director."
Standard #:	22VAC40-73-460-A
Complaint related:	Yes
Description:	Based on the review of facility records, interviews conducted with the facility Administrator and facility staff the facility failed to assume general responsibility for the health, safety, and well-being of the residents. Evidence: Resident #2-Documented date of admission 05/10/2022 Facility documentation and staff interviews conducted revealed that upon admission the resident was admitted to the facility?s safe and secure environment due to a diagnosis of having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and be unable to recognize danger or protect his own safety. Facility records also noted that the residents? Assessment of Serious Cognitive Impairment dated April 2022 notes under the heading Thoughts and Perception: ?Sundowning reported by husband.? On the day of admission facility staff #2 documented ?Sundowns. Verbally aggressive toward staff. Exit seeking behaviors noted. Since admission facility staff documented ongoing evening incidents and discussed during staff interviews the multiple times that the resident became very aggressive, combative, wandering throughout the unit and attempts and actual elopements from the facility. exit seeking, opening and closing her room door slamming it several times during the shift, trying to block bedroom door with table, intentionally pulled the fire alarm; Fire department arrived and turned off the alarm. Trying to unlock windows and yelling and fighting on care staff, came in the activity room and tried to get out into the courtyard, observed coming down the hallway with a shirt with no brief or pants on. After six days in care the facility submitted an incident report informing that resident #1 was involved in a physical altercation with another individual that caused injury to the resident. The resident?s 05/10/2022 Individualized Service Plan (ISP) that is signed and dated by facility staff #1 notes the following: Under the heading Description of Need and Date Identified: ?Psychosocial 05/06/2022.? Under the heading Services to be Provided: ?Resident does not have current or history of disruptive, aggressive, verbal or socially inappropriate behavior.? Facility documentation that was submitted for the inspector?s review and interviews conducted revealed that the facility did not document or indicate during interviews that a structured plan of care had been developed that supported the residents? ability of maintaining the highest level of independence or that established guidance for direct care staff to implement that would ensure that the aggressive behaviors had no further negative impact on the health, safety and well-being of the resident.
Plan of Correction:	FACILITY RESPONSE "Progress notes will be reviewed daily and if a change in condition and/or behaviors has occurred the care plan will be updated to reflect these changes. Any resident with aggressive behaviors will be referred to the Geri psychiatrist for evaluation. The facility will also consult with the company?s Memory Care Specialist for interventions on any resident who exhibits aggressive behaviors. Inservices on de-escalation, approach, and managing behaviors were conducted on 5/25, 6/14 and 6/30. Inservices on communication and approach were conducted on 7/26 and 7/28; inservices will be ongoing. Person Responsible: Executive Director, Director of Health and Wellness."
Standard #:	22VAC40-73-460-C
Complaint related:	Yes
Description:	Based on the review of facility records, interviews conducted with the facility Administrator and facility staff the facility failed to ensure that care was furnished in a way that fosters the independence of each resident and enables the residents to fulfill their potential. Resident #4: Documented date of admission 01/28/2022 Facility records submitted for the inspector?s review noted the following: The resident?s health and physical examination report document dated 01/27/2022 determined the resident to have mild dementia, anxiety and depression. Upon admission on 01/28/2022 facility staff #1 documented in part ?Mild confusion easily directed need ques for meals and dressing? On 01/31/2022; four days after admission facility direct care staff documented observed and reported behaviors of the resident walking around crying and being tearful about her dog. Later in the evening on 01/31/2022 facility staff documented that the resident was brought down to the front desk by another resident as resident #4 was wandering the community knocking on other residents doors asking for help. Facility staff documented that the resident taken with staff member to sit safety in the day room. A physicians? order dated 02/01/2022 notes; ?Move resident to Memory Care increase dementia with behavioral disturbances. The document also indicates that the resident would be moving from a room on the second floor of the facility to the memory care unit on the first floor. 02/03/2022: The resident was seen by the doctor for increased anxiety, auditory and visual hallucinations, noting that the resident was found on the balcony one night screaming for help and that the hallucinations have been going on x6-8 months The resident?s social data form document notes on page 2/2 ?Current behavioral and social functioning: ?Stresses at home in anticipation of moving. Can be paranoid people taking things, etc... sees initiation of people not there. No outside contact beside family and 1 friend. No outside interest or clubs.? Facility documentation and interviews conducted revealed that upon admission the resident was in a room on the 2nd floor of the facility and was not relocated to the first floor memory care unit until 02/08/2022 seven days after the 02/01/2022 physician?s order was written. Upon request the facility did not submit document that an accurate and detailed ISP was developed for resident #4 that identified the facility?s understanding of the resident?s current functioning, that provided interventions and guidance for implementing a structured plan of care that identified an activity?s program to assist with transfer trauma and the resident?s diagnosis.
Plan of Correction:	FACILITY RESPONSE "The facility will ensure that all ISPs demonstrate the facility?s understanding of the resident?s current functioning and is a structured plan of care that identifies interventions and guidance for assisting residents who have been identified as potentially experiencing transfer trauma. The facility will monitor all residents at admission and on an ongoing basis for signs of transfer trauma or a change in condition. The Director of Elements will ensure that all residents are encouraged to participate in activities and that all new admissions are encouraged to attend activities to assist with transition. Person Responsible: Executive Director, Director of Health and Wellness, Director of Elements"
Standard #:	22VAC40-73-560-E
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted with the facility Administrator and facility staff the facility failed to ensure that all resident records are kept current. Evidence: Facility Progress notes documentation is not being maintained: Resident #3 Documented date of admission 01/20/2022. The facility submitted Progress notes documentation that began on 01/31/2022. The complainant alleges that facility staff #1 requested that the resident be seen by the physician on 03/31/2022 due to the resident?s state of being. It is also alleged that the physician wrote an order on 03/31/2022 to check the resident for a UTI and that the facility did not follow through to ensure that the order was carried out. The Progress Notes documents that was submitted for the inspector?s review does not identify that facility staff documented every day since the resident was admitted to the facility; does not identify documentation of the staff?s interaction with the resident?s physician or family on 03/31/2022 or that an order was written. Facility staff documented on 04/03/2022 that a family member came to the facility and took the resident to the hospital to be ?checked out just to make sure she did not have an UTI.? Facility documentation noted that the resident was hospitalized beginning 04/03/2022 and returned to the facility n 04/20/2022. The facility did not ensure that the health care needs of the resident were being managed including the dissemination of information to families and staff. Resident #5- Documented date of admission 01/17/2022. Progress Notes documentation began on 02/14/2022 Resident #6-Upon request the facility did not submit for the inspector?s review documentation of the resident?s personal and social data information. A facility?s Service Plan Detail document signed by facility staff # 3 notes the move in date as 02/26/2022. The facility submitted Progress notes documentation that began on 03/01/2022. Also for resident #6: On 05/13/2022 the facility Administrator submitted a resident incident informing that during the 11-7 shift at 3:30a.m the resident was found on the bathroom floor and due to complaints of hip and leg pain the resident was sent out for emergency medical intervention. The resident never returned to the facility. Upon request the facility did not submit documentation of discharge.
Plan of Correction:	FACILITY RESPONSE "The facility will ensure that resident records are kept current and that proper documentation is maintained in each resident record. The Director of Health and Wellness will conduct a daily review of the progress notes/charting. The Director of Health and Wellness and/or the Executive Director will ensure that a progress note is made on all new admissions for the first seven days following admission. The Executive Director will ensure that an incident report is submitted to licensing for all incidents that involve a resident injury. The facility will ensure that all direct care staff are inserviced by 8/5/22 on how and when to document. Person Responsible: Executive Director, Director of Health and Wellness.
Standard #:	22VAC40-73-580-F
Complaint related:	No
Description:	Based on the review of facility records, interviews conducted with the facility Administrator and facility staff the facility failed to implement interventions as soon as a nutritional problem is suspected that include weighing residents at least monthly to determine whether the resident has significant weight loss (i.e., 5.0% weight loss in one month, 7.5% in three months, or 10% in six months); and notifying the attending physician if a significant weight loss is identified in any resident who is not on a physician-approved weight reduction program and obtaining, documenting, and following the physician's instructions regarding nutritional care. Evidence: Resident #3-Documented date of admission 01/20/2022: The resident?s physical examination report dated 01/14/20220 notes ?Progressive weight loss and protein malnutrition.? Facility staff #11 documented on the resident?s 02/21/2022 ISP that the resident will determine and order her own food. The facility did not submit for the inspectors? review a documented plan of care for direct care and or the facility?s dietary staff to implement to monitor the resident?s weight and daily dietary consumption.
Plan of Correction:	FACILITY RESPONSE "The facility will ensure that all residents are weighed at least monthly to determine whether the resident has significant weight loss and will notify the attending physician if a significant weight loss has occurred. The facility will obtain, document, and follow the physician?s instructions regarding nutritional care. The Director of Health and Wellness and the Executive Director will conduct an audit of all resident weights and will notify resident?s physicians if significant weight loss has occurred. To ensure compliance moving forward, an audit will be conducted monthly. Person Responsible: Executive Director, Director of Health and Wellness. "
Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on the review of facility records the facility failed to ensure that the facility keep current, and implement a written plan for medication management that includes procedures for administering medication and methods to ensure that each resident's prescription medications and any over-the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: Resident #2-Documented date of admission 05/10/2022-The eMAR document charting for June 2022 identified eight times the resident was administered medications due to medication not being available and onsite. Resident #3-Documented date of admission 01/26/2022-Facility staff documented fifteen times on the facility?s February, April and May 2022 eMAR Summary document that medications were not administered to the resident due to medication not being available and onsite.
Plan of Correction:	FACILITY REAPONSE "The facility will ensure that medications are available for administration and that all medications are administered as ordered. An audit will be conducted daily for medications that have been noted as not available and the shift supervisor will be notified so that follow up with the pharmacy can be immediately conducted." The facility will have the pharmacy conduct monthly reviews, medication cart audits, and medication pass observations for the next three months. Person Responsible: Executive Director, Director of Health and Wellness, Community Nurse, Shift Supervisor.