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 and June 15, 2022

Complaint Related: Yes

Technical Assistance:

Technical assistance offered to facility administrator to clarify issues which led to violations of regulations during this inspection. The Licensing Inspector reviewed the following standards with provider: 150-A, 250-A, 280-B, 320-A, 325-A, 325-B, 325-C, 440-A, 450-A, 460-A, 640-A, 650-A

Comments:

Responding to allegations made against the facility the inspector was on-site at the facility on 06/14/2022 between the approximate times of 9:30A.M until 6:10P.M and on 06/15/2022 between the approximate times of 10:00A.M until 3:51P.M The evidence gathered during the investigation supported some, but not all of the allegations; areas of non-compliance with standard(s) or law is contained within this report. A violation notice was 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 #:	22VAC40-73-150-C
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted with the facility Administrator, Director of Health and Wellness and other facility staff, the Administrator failed to be responsible for the general administration and management of the facility and failed to oversee the day-to-day operation of the facility. This shall include responsibility for: Evidence: Resident #1-Documented date of admission 01/31/2022 Ensuring the development, implementation, and monitoring of an individualized service plan for each resident: The preliminary and comprehensive ISPs were not developed for the resident by the timeframe required. An unqualified facility staff member developed two different ISPs for the resident. Recruiting, hiring, training, and supervising staff: The job description for the facility Administrator that was submitted for the inspector?s review notes in part under the heading Job Summary: ?Supervises staff in accordance with company policy? ?Ensures provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs, including those services identified in the residents' pre-admission appraisal.? The job description for facility staff #14 that was submitted for the inspector?s review notes in part under the heading Job Summary ?Responsible for maintaining a current accounting of all medications residents are taking and the documentation required for that process?. In the months of February, March, April and May 2022 facility staff documented a total of forty-two times that the resident was not administered prescribed medications-noting ?unavailable or waiting on the pharmacy?. The review of facility records revealed four different MARs for the month of May 2022 that noted discrepancies to the other. The facility and direct care agency staff administered medication/ performed a procedure regarding resident #1 without a signed physician?s order. Facility staff and direct care agency staff are documenting the administration of an as needed (PRN) medication but does not documentation the behaviors observed or assessed that warranted the medication being administered. Multiple facility documents are being maintained regarding daily staffing but the documents are not consistent with the other. Facility records are not being maintained for the resident or the direct care agency staff. The facility Administrator did not provide oversight and supervision to facility staff #14.
Plan of Correction:	FACILITY RESPONSE "he Administrator will be onsite and provide supervision/oversight of day to day operations of the community. Should the administrator be absent a designee will be clearly denoted and responsible for the supervision until the administrator returns. Person Responsible: Executive Director and/or Desginee"
Standard #:	22VAC40-73-250-A
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted with the facility Administrator and facility staff the facility failed to ensure that a record was established for each staff person. Evidence: Agency direct care staff #s 4, 5, 6, 7, 8, 9, 10 and 13- Documented date of hire unknown. Facility document charting for 04/17/2022 that was submitted for the inspector?s review identifies that direct care agency staff #s 4, 5, 6, 7, 8, 9, 10 and 13 were assigned to work at the facility on 04/17/2022. Upon request during the review of facility records on 06/14 and 15/2022 the facility did not submit for the inspector?s review documented evidence that a facility record had been created for staff #s 4, 5, 6, 7, 8, 9, 10 and 13 that included a criminal records report and sworn disclosure statement, personal and social data, documentation of orientation and training, and credentials.
Plan of Correction:	FACILITY RESPONSE-"The facility will ensure that all facility staff, including agency, have a record established and maintained at the facility. An audit of all current employee files will be conducted and areas that are out of compliance will be corrected. 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:	No
Description:	Based on the review of facility records and interviews conducted with the facility Administrator and other facility staff the facility failed to ensure that the assisted living facility have 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 #1- Documented date of admission 01/31/2022 The complainant alleged that on Easter Sunday (04/17/2022) there was only one direct care staff in the safe and secure environment of the facility where the resident resides. The facility?s Employee Punch Report document that was submitted for the inspector?s review revealed that facility staff #s 1, 2 and 3 were the only facility staff assigned to work at the facility on 04/17/2022 during the 7:00A.M-3:00P.M shift. A facility?s shift document charting for 04/17/2022 during the 7:00A.M-3:00P.M shift identified facility staff #1-registered medication aide as the only staff with the responsibility for administering medications to approximately thirty-one facility residents. Facility staff #2 is not identified on the facility?s 04/17/022 shift document as being assigned to the assisted living program or the safe and secure environment.
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 facility staff the facility failed to ensure that within the 30 days preceding admission, a physical examination was conducted by an independent physician. Evidence: Resident #1- Documented date of admission 01/31/2022 Responding to the inspector?s request to review all physical examination reports for the resident the facility Administrator submitted a document via email on 06/27/2022. The document is dated 01/18/2022 and only contained three of the four pages. The 01/18/2022 physical examination report did not include Page 3-the physician?s assessment of the resident regarding ?Diagnosis or significant problems, Recommendations for care: Medications, Diet and Therapy.? The facility did not obtain a complete physical examination report for the resident within the 30 days preceding admission as required.
Plan of Correction:	FACILITY RESPONSE-"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:	Based on the review of facility records and interviews conducted with the facility Administrator and facility staff 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 was completed. Evidence: Resident #1-Documented date of admission 01/31/2022 Upon request the facility did not submit documentation that a fall risk rating was conducted within 30 days after admission.
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:	No
Description:	Based on the review of facility records and interviews conducted with the facility Administrator and facility staff the facility failed to ensure that fall risk rating was reviewed and updated after a fall. Evidence: Resident #1-Documented date of admission 01/31/2022 The facility?s Progress notes document that was submitted for the inspector?s review identified five different incidents of the resident having falls in February 2022; falls on 04/24,27/2022 a fall on 05/02/2022. Upon request the facility did not submit documentation that fall risk ratings were conducted after each of these falls.
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 falls a fall. 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:	No
Description:	Based on the review of facility records and interviews conducted with the facility Administrator and facility staff the facility failed to maintain documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls. Evidence: Resident #1-Documented date of admission 01/31/2022 The facility Administrator submitted an incident report to the regional licensing office via email on 03/17/2022 informing of a fall with injury. Since the date of admission the facility documented a total of 10 incidents of the resident having falls. Upon request the facility did not submit for the inspector?s review documentation that an analysis of the circumstances of the falls and interventions that were initiated to prevent or reduce risk of subsequent falls was conducted.
Plan of Correction:	FACILITY RESPONSE- "The facility will ensure that a fall risk analysis on the circumstances of the fall and interventions are initiated to prevent and reduce the risk of subsequent falls is reviewed and updated after a fall. 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 #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted with facility staff the facility failed to ensure that all residents of and applicants to assisted living facilities were assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition. Evidence: Resident #1- Documented date of admission 01/31/2022 Responding to the inspector?s inquiry and the request for all UAIs conducted prior to and since the date of admission the facility submitted two unsigned UAIs dated 02/02/2022. Via email on 07/05/2022 the facility Administrator reported that ?The system indicates that (former facility staff identified) completed the 2/2 assessment that is unsigned?. The facility Administrator did not submit the electronic UAI she identified in her email. During interviews the facility Administrator reported concerns of the UAI document from the being removed from the record but offered no effort of her contacting the previous facility to obtain their most recent UAI assessment.
Plan of Correction:	FACILITY RESPONSE- "The facility will ensure that all residents will have a UAI performed prior to admission, annually and when there is a significant change in condition. An audit of all charts will be conducted to ensure that UAIs are in the resident record. Person Responsible: Executive Director, Director of Health and Wellness."
Standard #:	22VAC40-73-450-A
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted with facility staff the facility failed to ensure that on or within seven days prior to the day of admission, a preliminary plan of care is developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. The preliminary plan shall be developed by a staff person who has successfully completed the department-approved individualized service plan (ISP) training, provided by a licensed health care professional practicing within the scope of his profession. Evidence: Resident #1- Documented date of admission 01/31/2022 For clarification the facility Administrator stated that the resident?s 03/21/2022 ISP that was submitted for the inspector?s review was developed by facility staff #15. Upon request for documentation that facility staff #15 has Virginia credentials noting completion of UAI and ISP training the facility Administrator responded via email ?We do not have this?. Upon request the facility did not submit for the inspector?s review documentation that identifies facility staff #15 as a qualified assessor or that a preliminary ISP was developed for the resident prior to the documented date of admission. The resident?s 01/18/2022 Health and Physical Examination report notes in part ?Patient is weak in lower body. Able to transfer with 1 person/stand by assist and that the resident depends on wheelchair for transportation and occasionally the resident will attempt to get out of bed. ' 02/05/2022: Facility staff #14 documented ?Resident continues to adjust without difficulty. Pleasant and cooperative. Needs are anticipated by staff. Tolerates care and medications without difficulty?. Facility staff however documented that the resident had falls on 02/06, 08/2022 and on 02/15/2022 facility staff documented ?Resident constantly attempting to stand, has needed much re-direction, all without success. Staff taking lunch orders, this writer went into Resident's room to get sweater, came back to activity room and found Resident in hallway, sitting on foot rest of w/c.? 02/16/2022: At 7:27p.m ?Resident witnessed sliding from wheel chair. 02/16/2022 at 10:16p.m ?Resident slid out of wheel chair in the presence of staff. Facility records submitted for the inspector?s review revealed a 03/21/2022 document titled Service Plan. Under the heading Action facility staff #15 documented ?Potential: Moderate Resident is at a moderate potential for falls. (Resident identified) has fall mats, and a low hospital bed. She also has a wheelchair. ? The 03/21/2022 Service Plan document is not identified as the preliminary ISP and is not documented to clarify/identify that direct care staff were provided guidance on implementing a plan for increased supervision.
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. The Director of Health and Wellness and Executive Director will attend ISP training by August 15, 2022. An inservice will be conducted with direct care staff on where to locate the ISPs; all direct care staff will be required to review the ISPs for all residents to whom they provide care. 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 and interviews conducted with the facility Administrator, facility direct care staff, the facility failed to ensure that care was furnished in a way that fosters the independence of each resident and enables him to fulfill his potential. Evidence: Resident #1- Documented date of admission 01/31/2022 The facility?s Progress Notes document charting for February 2022 and the eMar Summary document charting for 02/03/2022 noted the following: '02/03/2022 at 6:42a.m facility staff documented ?Resident slept all night and took morning meds. aide reports she has a headache and wanted to stay in the bed?. 02/03/2022 at 10:27A.M facility staff #14 documented on the facility?s eMAR Summary document that she administered 0.5 mg of the medication Lorazepam to resident #1 due to ?increased anxiety not relieved by change in environment?. At 10:33A.M facility staff #14 also documented ?Resident noted with nausea and vomiting this am. Given ginger ale and crackers with some relief. No further concerns voiced?. After four days in care the facility staff #14 documented that the resident was medicated without documenting specific behaviors observed that clarified an understanding of transfer trauma. On 02/21/2022 at 2:38p.m a direct care agency staff documented ?resident has been asking for daughter (identified) q shift given prn Ativan for anxiety, uneffective.? In March, April and May 2022 facility direct care staff continued to document resident falls, and that the resident was administered medications due to being agitated. The facility did not provide documented evidence of individually tailored service delivery noting actions taken regarding the observed behaviors other than to medicate. The facility admitted the resident without documentation of the resident?s diagnosis or significant problems or recommendations for care from the resident?s physician that would assist with developing a structured plan of care that established guidance for direct care staff to implement.
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 fosters independence of each resident and enables him to fulfill his potential. 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 behaviors will be referred to the Geri psychiatrist for evaluation. The facility will also consult with the company?s Memory Care Specialist for interventions and communicate these interventions with the direct care team. All staff who administer medications will be inserviced on the facility?s medication management plan. 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 #:	22VAC40-73-640-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 #1-Documented date of admission 01/31/2022 The facility?s February, March, April and May 2022 eMAR Summary document that was submitted for the inspector?s review revealed multiple days that medications were not administered to the resident. 02/01/2022: at 8:00A.M- 200 mg Hydroxychloroquine ?med not available?. 02/05/2022: at 6:00A.M- 0.125ng Hyoscyamine ?waiting on pharmacy?. 02/07/2022: at 8:00A.M- 0.005% Latanoprost ?med not available?. 02/08/2022: at 12:00A.M- 0.125ng Hyoscyamine ?medication not available?. 02/16/2022: at 5:00P.M-500 Unit/GM Bactrium External Ointment ?did not receive?. 02/19/2022: at 8:00P.M- 3mg Melatonin- ?awaiting med from pharmacy?. 02/20/2022: at 5:00P.M- 400mg Cranberry concentrate ?awaiting on pharmacy?. 02/20/2022 at 8:00P.M- 3mg Melatonin ?awaiting med from pharmacy?. 02/21/2022: at 8:00A.M- 20 mg Furosemide ?not given reordered?. 02/21/2022: at 8:00A.M- 400mg Cranberry concentrate ?not given reordered?. 02/21/2022: at 8:00A.M- 10 mg Pravastatin ?not given reordered?. March: On eight different days facility staff documented that medications were not administered to the resident because the medications were not available. April: Thirteen (13) different days? facility staff documented that medications were not administered to the resident because the medications were not available. May: Ten different days? facility staff documented that medications were not administered to the resident because the medications were not available
Plan of Correction:	FACILITY RESPONSE- "All staff who administer medications will be inserviced on the facility?s medication management plan. 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."
Standard #:	22VAC40-73-650-A
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted with the facility Administrator and facility staff the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications. Evidence: Resident #1-Documented date of admission 01/31/2022 02/15/2022: Facility staff documented ?New Order received: obtain urine for dipstick test. At 10:23 P.M facility staff wrote ?Resident urine dipstick abnormal.DON made aware.Will continue to monitor?. On 02/22/2022 a direct care agency staff documented on the facility?s eMAR Summary document that the resident was administered a 10mg Bisacodyl rectal suppository for agitation. The resident?s physician?s orders dated 01/18/2022 does not identify the medication Bisacodyl. In response to the inspector?s request to review all physician?s orders for resident #1-the only two physician?s orders that were submitted for the inspector?s review for the month of February 2022 were dated 02/08/2022 and 02/22/2022. Neither order listed Bisacodyl as a prescribed medication or identified the 02/15/2022 order to collect urine
Plan of Correction:	FACILITY RESPONSE- "The facility will ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed or discontinued by the facility without a valid order from a physician or other prescriber. Orders will be verified by the Director of Health and Wellness or designee as medications are delivered on the cycle fill. 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."