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: July 8, 2022 and July 11, 2022

Complaint Related: No

Comments:

Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/08/2022 ?between the approximate times of 3:24p.m until 6:36p.m. On 07/11/2022 between the approximate times of 11:06a.m until 5:16p.m. Number of residents present at the facility at the beginning of the inspection: 55 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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. 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 #:	22VAC40-73-1100-A
Description:	Based on the review of facility records the facility failed to ensure that prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility obtained the written approval as required. Evidence: Resident #7-Documented date admission 06/16/2022 Based on observation of the resident on 07/11/2022 in the safe and secure environment, the review of facility records, staff interviews and upon request the facility did not submit for the inspector?s review documentation that the written approval for placement was obtained prior to or since placement and kept in the resident's file.
Plan of Correction:	FACILITY RESPONSE- "The facility will ensure that prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility obtained the written approval as required. The facility was able to locate the written approval that was signed on the resident?s date of admission (6/16/2022); however, this document was not produced for the licensing inspector on the date of inspection. An audit of the files for all residents who reside on the safe, secure environment will be conducted to ensure the written approval is in place. Moving forward, all new resident files will be audited prior to or on the day of admission to maintain compliance. Person Responsible: Executive Director, Business Office Director"
Standard #:	22VAC40-73-70-A
Description:	Based on interviews conducted the facility Administrator did not report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: Resident #1-Documented date of admission 02/15/2022 07/08/2022: During the 3-11 shift two facility direct care staff members were observed donning PPE gear before entering the residents? room. Upon inquiry the facility Administrator informed the inspector that the resident tested positive for COVID-19 on 07/01/2022. The incident report was not received at the department until 07/13/2022. Resident #2-Documented date of admission 05/28/2022 The Progress notes document charting for 06/26/2022 notes in part ?Resident has tested positive for COVID.? The facility did not submit an incident report informing of the resident?s status.
Plan of Correction:	FACILITY RESPONSE- "The facility will ensure that any incident that has negatively affected or threatens the life, health, safety or welfare of any resident is reported to the regional licensing office within 24 hours. Training will be conducted with all staff on communication and the process for reporting incidents that negatively affect or threatens the life, health, safety or welfare of any resident to the facility Administrator and Director of Health and Wellness. The Administrator and DHW will report all incidents within 24 hours. Person Responsible: Executive Director, Director of Health and Wellness."
Standard #:	22VAC40-73-120-A
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that orientation and training required in subsections B and C of this section occurred within the first seven working days of employment. Until this orientation and training is completed, the staff person may only assume job responsibilities if under the sight supervision of a trained direct care staff person or administrator. Evidence: Facility staff: #1- Documented date of hire 10/11/2021 #3- Documented date of hire 04/19/2022 #5- Documented date of hire 04/19/2022 #6- Documented date of hire 05/10/2022 Upon request the facility did not submit for the inspector?s review documentation that orientation was provided to staff?s 1, 3, 5 and 6 prior to or since date of hire.
Plan of Correction:	FACILITY RESPONSE-"The facility will ensure that all staff receive orientation and training within the first seven working days of employment. The facility has implemented an onboarding program that includes the requirements in subsections B and C of this section. All facility staff are required to attend this onboarding within 7 working days of the date of employment or they are removed from the schedule until they can attend. Any current facility staff who do not have documentation of receiving this training will be required to attend an upcoming onboarding session."
Standard #:	22VAC40-73-150-C
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure the development, implementation, and monitoring of an individualized service plan for each resident is based on assessed needs Evidence: During interviews the facility Administrator informed that facility staff #8 is responsible for developing the residents ISPs, supervising the medication management program, and following up with resident care needs. Medications are not administered per physician?s orders because the medication are not onsite, the care plans are not individualized or, based on assessed need, not developed with the resident or legal representative and not developed by the timeframe required Resident #7 A direct care agency staff documented an inquiry for the resident to have a high back wheelchair and cushions to help with posture and ?Must chart on her behaviors, times, days and what is going on.? The resident?s Progress Notes documentation that was submitted for the inspector?s review does not identify that facility staff #8 followed up regarding the high back wheel chair and behaviors. The progress notes documentation requested beginning at date of admission to 07/08/2022 is not documented to note that facility staff #8 charted at all. The planning, organizing, developing and providing the overall guidance to direct care staff to assist with the delivery of resident services is not being implemented.
Plan of Correction:	TFACILITY RESPONSE- "he facility will ensure that an ISP is developed and implemented for each resident, and that the medication management plan is supervised and monitored on a daily basis. The Director of Health and Wellness and Executive Director will attend ISP training. The Director of Health and Wellness will receive additional training on the facility?s medication management plan, including the process for supervising and implementing the plan. All people responsible for administering medications will receive training on the facility?s medication management plan. Person Responsible: Executive Director, Director of Health and Wellness."
Standard #:	22VAC40-73-250-A
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that personal and social data is maintained on staff and included in the staff record. Evidence: Facility staff #1 The review of facility records revealed three different dates of hire: 10/11/2021, 04/17/2022 and 05/09/2022.
Plan of Correction:	FACILITY RESPONSE- "The facility will ensure that personal and social data is maintained on all staff and included in the staff record. An audit on all employee files has been conducted and missing documentation is being collected from the staff with incomplete records. Moving forward, all staff records will be audited within 3 days of hire to ensure all required documentation is in the record. Person Responsible: Executive Director and Business Office Director"
Standard #:	22VAC40-73-250-C
Description:	Based on the review facility records and interviews conducted the facility failed to ensure that any person required by this chapter to obtain a criminal history record report must be ineligible for employment if the report contains convictions of the barrier crimes. Evidence: Facility staff #6- Documented date of hire 05/10/2022 The review of facility records on 07/11/2022 revealed barrier crimes on the criminal records report. The facility?s Employee Punch Report document noted that facility staff #6 provided care services and supervision to facility residents on 05/16, 29, 31/2022.
Plan of Correction:	FACILITY RESPONSE- "The facility will ensure that a criminal history is submitted for every employee prior to his or her start date. Facility staff #6 was not employed after the facility received the criminal history"
Standard #:	22VAC40-73-250-D
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 #5--Documented date of hire 04/19/2022 Facility records submitted for the inspector?s review is not documented to identify that facility staff #5 is free of tuberculosis in a communicable form. The facility?s Employee Punch Report document notes that facility staff worked as a direct care staff member for seven days in May 2022.
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."
Standard #:	22VAC40-73-250-D
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 #5--Documented date of hire 04/19/2022 Facility records submitted for the inspector?s review is not documented to identify that facility staff #5 is free of tuberculosis in a communicable form. The facility?s Employee Punch Report document notes that facility staff worked as a direct care staff member for seven days in May 2022.
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"
Standard #:	22VAC40-73-320-A
Description:	Based on the review of facility records the facility failed to ensure that within the 30 days preceding admission, a person shall have a physical examination by an independent physician that included 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. Resident #3-Documented date of admission 04/01/2022 Review of the resident?s record revealed that the 03/28/2022 physical examination report did not include: (1)-A statement that the individual does not have a prohibited condition. (2)- A statement that specifies whether the individual is or is not capable of self- administering medication Resident #4-Documented date of admission 02/28/2022 Review of the resident?s record revealed a 02/18/2022 Report of TB Screening document that is signed by a physician. Answer to the question whether the individual is free of tuberculosis in a communicable form is blank. The document does not indicate whether the resident is free of tuberculosis in a communicable form
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-325-A
Description:	Based on the review of facility records the facility failed to ensure that for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating is completed. Resident #1-Documented date of admission 02/15/2022 Resident #2-Documented date of admission 05/28/2022 Resident #3-Documented date of admission 04/01/2022 Resident #4Documented date of admission 02/28/2022 Resident #5-Documented date of admission 05/27/2022 Resident #6-Documented date of admission 05/16/2022 Resident #7-Documented date of admission 06/16/2022 Resident #8-Documented date of admission 03/07/2022 Upon request the facility did not submit for the inspector?s review documentation that a fall risk rating had been conducted for residents 1-8, within 30 days after or since 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
Description:	Based on the review of facility records the facility failed to ensure that the fall risk rating was reviewed and updated under after a fall. Resident #3-Documented date of admission 04/01/2022 04/05/2022: The facility?s Progress Notes document notes that the resident said she fell on the bathroom floor and hit her right knee. Upon request the facility did not submit for the inspector?s review documentation that a fall risk rating had been conducted.
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
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. Resident #3-Documented date of admission 04/01/2022 Upon request the facility did not submit for the inspector?s review documentation that a fall risk analysis was conducted regarding the 04/05/2022 fall.
Plan of Correction:	FACILITY RESPONSE- "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 #:	22VAC40-73-450-A
Description:	Based on the review of facility records the facility failed to ensure that on or within seven days prior to the day of admission, a preliminary plan of care was developed 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: Resident #2-Documented date of admission 05/28/2022 The resident?s Individualized Service Plan (ISP) dated 05/23/2022 was signed by the resident on 07/07/2022. Facility records and interviews conducted did not indicate that the ISP was developed in conjunction with the resident or other individuals involved with the resident. Resident #3-Documented date of admission 04/01/2022 In response to the inspector?s request to review all ISPs for the resident-the facility submitted two ISPs dated 04/06/2022 signed by facility staff #8 and 05/25/2022. Facility staff #11 is not authorized but also signed the ISP 04/06/2022. Facility staff documented on the resident?s 04/06/2022 ISP that the resident ?does not require assistance with medication administration?. The resident?s 03/28/2022 physical examination report does not document whether the resident is capable of self-administering medications. Facility MARs charting for April 2022 notes that facility staff administers the resident?s medication. Neither ISP document is signed by the resident or a legal representative nor identify as the preliminary ISP. Resident #7-Documented date of admission 06/16/2022. On 06/17/2022 direct care agency staff noted in part that the resident is total care, difficult to redirect and cannot communicate what she needs or wants. The resident?s 06/17/2022 ISP notes under the heading Services To Be Provided- ?Resident is not able to communicate effectively and make their need known without assistive device.? Facility staff #8 did not identify what assistive device is need by the resident or staff?s responsibility for implementing care. The residents ISP are not developed based on the UAI; medical reports; interview with the resident; fall risk rating and any additional information necessary to meet the care needs of the resident.
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 #:	22VAC40-73-450-D
Description:	Based on the review of facility records the facility failed to ensure that when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each must be included on the individualized service plan. Evidence: Resident #7-Documented date of admission 06/16/2022 Facility staff documented on the day of admission that the resident is total care and that the resident was admitted to hospice (agency identified). The resident?s 06/17/2022 ISP notes in part that the resident is on hospice services- ?Nurse twice a week and as needed. Caregiver 7 days a week? and that the Medication Care Manager is responsible for providing the services. The resident?s care plan is not documented to identify the agreed upon coordinated plan of care for the resident. The facility failed to ensure that the services provided by each is included on the individualized service plan.
Plan of Correction:	FACILITY RESPONSE- "The facility will ensure that the ISP includes information on the coordinated plan of care for all residents who receive hospice services and that the services provided by each is included on the ISP. 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 includes a coordinated plan of care for all residents who receive hospice care. Person(s) Responsible: Director of Health and Wellness and Executive Director"
Standard #:	22VAC40-73-450-F
Description:	Based on the review of facility records the facility failed to ensure that Individualized service plans were updated at least once every 12 months and as needed for a significant change of a resident?s condition. Resident #3-Documented date of admission 04/01/2022 April 2022 facility staff documented the need for physical therapy, home health services for wound care. Facility staff also documented ?ted hose knee high apply only to right lower extremity on in a.m. and off at bedtime.? The resident?s 04/06/2022 and 05/25/2022 ISPs are not documented to note wound care, physical therapy or ted hose as an assessed and or observed need.
Plan of Correction:	FACILITY RESPONSE- "The facility will ensure that each resident?s ISP is updated at least once every 12 months and as needed for a significant change of a resident?s condition. 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 all resident care plans are reflective of any significant change in condition. Person(s) Responsible: Director of Health and Wellness and Executive Director"
Standard #:	22VAC40-73-640-A
Description:	Based on the review of facility records the facility failed to ensure that a medication management plan was implemented that included: ' 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. Resident #5- Facility staff documented on 07/01, 07/2022 that the resident?s prescribed ear medication was not onsite and available for administration. . Resident #7- Documenting on 07/02/2022 for 8:00a.m and 1:00p.m facility noted that the medication buspirone to be administered three times a day was not onsite and available for administration. ' Procedures for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order. Evidence: Resident #2-Documented date of admission 05/28/2022 07/08/2022: During the observation of the medication pass during the 3-11 shift with facility staff #7, the spouse of resident #2 informed the medication aide (#7) of the changes that the resident?s physician made regarding the resident?s blood glucose readings. On 06/13/2022 facility staff #3 documented in the Progress Notes document that a new sliding scale order from the doctor was received and faxed to the pharmacy. Prior to interacting with resident #2 facility staff #7 reviewed the MARs and determined that no new orders had been made regarding the resident?s blood glucose readings. ' Methods for monitoring medication administration and the effective use of the MARs for documentation. Evidence: Resident #7- Documented date of admission 06/16/2022 While facility staff #1 documented on the back of the MAR for 07/02/2022 at 8:a.m that the medication Trazodone was not administered ?pending rx? facility staff #1 also documented on the front of the MAR that the medication was administered.
Plan of Correction:	FACILITY RESPONSE- "The facility will ensure that the medication management plan is implemented and includes (1)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; (2)procedures for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order, (3) Methods for monitoring medication administration and the effective use of the MARs for documentation. (1)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. (2)An audit will be conducted daily for new orders or changes in orders to ensure that medication orders have been accurately transcribed to the MAR. (3)A review of missed medications will be conducted daily to monitor medication administration and effective use of the MARS for documentation. The pharmacy will also conduct a monthly med cart audit and med pass observation. 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."
Standard #:	22VAC40-73-650-E
Description:	Based on the review of facility records the facility failed to ensure that the resident's records contained the physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's oral order. Orders must be organized chronologically in the resident's record. Evidence: Evidence: Resident #2-Documented date of admission 05/28/2022 On 06/13/2022 facility staff #3 documented that a new sliding scale order from the doctor was received and faxed to the pharmacy. Upon request the facility did not submit for the inspector?s review the signed physician?s order referenced by facility staff #3.
Plan of Correction:	FACILITY RESPONSE- "The facility will ensure that all resident?s records contain the physician?s or other prescriber?s signed written order or a dated notation of the physician?s or other prescriber?s oral order, and all orders will be organized chronologically in the resident?s record. All orders will be reviewed daily to ensure they are signed and entered into the resident?s chart. Person Responsible: Executive Director, Director of Health and Wellness, Community Nurse, Shift Supervisor."
Standard #:	22VAC40-73-720-A
Description:	The facility will ensure that all resident?s records contain the physician?s or other prescriber?s signed written order or a dated notation of the physician?s or other prescriber?s oral order, and all orders will be organized chronologically in the resident?s record. All orders will be reviewed daily to ensure they are signed and entered into the resident?s chart. Person Responsible: Executive Director, Director of Health and Wellness, Community Nurse, Shift Supervisor.
Plan of Correction:	FACILITY RESPONSE- "The facility will ensure that a written Do Not Resuscitate (DNR) order is included in the individualized service plan. An audit of all resident charts will be conducted to ensure that the ISP includes a written DNR for each resident who has such an order. Person(s) Responsible: Director of Health and Wellness and Executive Director "