VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Ginter Hall South
11300 Mall Court
N. chesterfield, VA 23235
(804) 794-7770

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: Sept. 19, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND

Comments:

Type of Inspection: Complaint Date of Inspection and time that the licensing inspector was on site: 9/19/2022, 2 pm - 5 pm The licensing inspector completed a tour of the physical plant that included the kitchen and resident rooms (3rd floor) Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Additional Comments/Discussion: A monitoring inspection was completed to follow-up on a self-reported incident. A complaint was received by VDSS Division of Licensing on 9/12/2022 regarding allegations in the areas of Administration and Administrative Services, Personnel, Staffing and Supervision, Building and Grounds, Resident Accommodations and Related Services and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 35 censing inspector completed a tour of the physical plant that included the kitchen and resident rooms (3rd floor) Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Additional Comments/Discussion: A monitoring inspection was conducted to follow-up on a self reported incident on 8/29/2022. Subsequently, a complaint was received regarding the incident from the VDH. VDH is monitoring the situation. The evidence gathered during the inspection did not determine any non-compliance with applicable standards or law at this time. The department 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. An exit meeting was conducted to review the inspection findings. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804) 662-7454 or by email at yvonne.randolph@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-250-C
Complaint related:	Yes
Description:	Based on a review of three staff files, the facility failed to maintain documentation and verification of medication aide provisional authorization from the Virginia Board of Nursing. Evidence: Documentation and verification of medication aide provisional authorization was not found during a review of the file for staff # 2.
Plan of Correction:	Documentation was misplaced and staff member had yet to take the board exam She was removed as a Medication Aide and placed on the schedule as a PCA.
Standard #:	22VAC40-73-260-A
Complaint related:	Yes
Description:	Based on a review of direct care staff 1st Aid certifications, one staff does not have certification in 1st Aid. Evidence: The facility did not have documentation to support that staff # 7 had current 1st Aid certification.
Plan of Correction:	Direct care staff was scheduled to be in CPR/FA class on 9/13/22, however due to car issues was unable to attend. She is scheduled for the next class on 10/25/2022. She never worked without having someone working with her that is CPR/FA certified.
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on a review of 5 resident files, the individualized service plan (ISP) for one resident was not signed and dated by the resident or legal representative of the resident. Evidence: A review of the file for resident# 1 found that the current ISP dated 3/31/22 was not signed or dated by the resident or the legal representative of the resident.
Plan of Correction:	ISP was emailed to family on individualized service plan 3/31/2022, however was never returned to GHS signed. ISP was reviewed with the family and signed on 9/22/2022.
Standard #:	22VAC40-73-680-A
Complaint related:	Yes
Description:	Based on a review of three staff files, medications are being administered to residents by a staff person who is not currently registered with the Virginia Board of Nursing as a medication aide. Evidence: A review of the file for staff# 1 found an expired registration (expiration date is 5/31/22) with the Virginia Board of Nursing.
Plan of Correction:	Due to the medication aide recently moving, she had lost her PIN and had requested a new one from the Virginia Board of Nursing. PIN number was received and license was renewed
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on a review of physician orders, medication administration records (MARs)and drug count sheets, medications were not administered in accordance with the physician's or other prescriber's instructions. Evidence: Medication was discovered by licensing staff in the facility's parking lot. As a result, licensing staff completed a review of medication storage, availability and administration for three residents. Licensing staff found medications that were not administered per physician orders: 1. Resident # 10 has an order for Lorazepam Oral Concentrate: Give 0.25 ml sublingually 3 times a day - scheduled. Lorazepam scheduled for administration at 9 am on 9/19/22 was not given. There was a note "med not given-given early". The Drug Count sheet documents that the medication was given at 6 am on 9/19/22. 2. Resident # 11 has an order for Lorazepam 1 mg: 1 tablet by mouth every 8 hours as needed for anxiety. Lorazepam was not given every 8 hours. The Drug Count sheet documents Lorazepam being administered on 8/25/22 at 3: 15 pm and 9:00 pm, on 8/28/22 being administered at 10:00 am and at 5:00 pm and on 9/20/22 being administered at 11 :00 am and 3:00 pm.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on a review of medication administration records (MARs) for September 2022 for four residents, MARs did not have the date, time given and initials of staff administering medications/treatments. Evidence: 1. The MAR for resident# 1 states knee brace -wear flexible knee brace every day and remove at bedtime. Placement of knee brace is not documented on 9/2, 9/ 6, 9/7, 9/8, 9/9 or 9/11. The box on the MAR to document that the placement occurred was blank. 2. The MAR for resident # 2 states oxycodone 10 mg- 1 tab by mouth 3 times a day and gabapentin 100mg - 2 capsules (200 mg) by mouth 3 times a day. The administration of oxycodone and gabapentin is not documented as being administered on 9/6 and 9/8. The boxes on the MAR to document are blank.
Plan of Correction:	We have completed med pass observations on all medication aides as well as med cart audits. We have scheduled a Med Tech Refresher to include review of the narcotic sheet by our pharmacy, Family Care.
Standard #:	22VAC40-73-870-D
Complaint related:	Yes
Description:	Based on an inspection of the building and a random resident rooms along with interviews and observations of residents, the facility is not free of infestations of insects and vermin and their breeding places. Evidence: A random inspection of resident rooms found evidence of bed bug infestation in two resident rooms: 1. Two licensing inspectors observed excrement stains (dark spots) on the walls in the room of resident # 6. 2. Two licensing staff observed blood-colored stains on the pillow and excrement stains (dark spots) on the walls and bed sheets of the resident of the room of resident # 2. Two licensing staff observed red, swollen areas on the arms, hands, fingers and upper chest of resident# 6.
Plan of Correction:	We are currently set up for monthly monitoring with Clean Heat Defense. If signs of bugs are seen in between services, then Clean Heat comes out for special services. Clean Heat was called the day of inspection and was out the next morning. They treated the two rooms where evidence was found as well as treated the entire third floor.