VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Aable Rest Home
31 Stoney Point Road
Cumberland, VA 23040
(804) 492-4135

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: March 4, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3-4-22 from 10:20 a.m.- 2:30 p.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 2-28-22 regarding allegations in the area(s) of: resident care and supervision. Number of residents present at the facility at the beginning of the inspection: 19 Number of resident records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: administration and administrative services, staffing and supervision, resident care and related services. 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov Violation Notice Issued: Yes A copy of this document will be sent to the licensee/provider for signature.

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on a complaint received and an interview with facility staff, the facility failed to 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: -The facility failed to notify the regional licensing office that Resident # 4 hit her head due to a seizure and went to the ER where she had staples applied on 1-30-22. The licensing office only became aware of the incident when a complaint was received on 2-28-22. -The facility also failed to inform the licensing office that Resident # 2 was hospitalized in ICU due to a diabetic ketoacidosis in January 2022. -The facility failed to inform the licensing office that Resident # 3 was taken to the hospital on September 25, 2021 when he was found unresponsive. Licensing only became aware of the incident during the complaint investigation on 3-4-22.
Plan of Correction:	Moving forward the administrator will notify the license inspector within 24 hours of all injuries that result in a hospital visit.
Standard #:	22VAC40-73-300-B
Complaint related:	No
Description:	Based on an interview with staff, the facility failed to ensure that a method of written communication is utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaint and incidents or injuries related to physical or mental conditions. Evidence: The facility did not provide a communication log upon request. Staff # 1 stated that the facility did not keep a communication log and staff inform each other of various issues.
Plan of Correction:	All staff has been made aware of the communication log book.
Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on a review of resident records the facility failed to ensure that the Uniform Assessment Instrument (UAI) shall be completed at least annually, and whenever there is a significant change in the resident?s condition. Evidence: -The record for Resident # 3 contained a UAI that was last dated 7-17-19. -Staff # 1 stated that it has been difficult during the COVID pandemic to get UAIs completed by UAI assessors.
Plan of Correction:	Administrator will continue to request for UAIs to be completed by local dss and will keep records of contact logs.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on a review of resident records the facility failed to ensure that the individualized service plans (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: -The UAI for Resident # 1 (admit date: 7-1-97) dated 10-5-21 indicates that the resident receives mental health case management. However, the resident's most recent ISP dated 12-21-21 does not address mental health case management. -The Uniform Assessment Instrument (UAI) for Resident # 2 (admit date: 12-17-03) dated 1-2-22 indicates that the resident receives mental health case management. However, the resident's most recent ISP dated 1-12-22 does not address mental health case management. -The UAI for Resident # 3 (admit date: 6-29-16) dated 7-17-19 indicated that the resident needs help with using the phone. However, the resident?s most recent ISP dated 1-12-22 does not address phone use. -The UAI for Resident # 4 (admit date: 12-28-15) dated 1-20-22 indicates that the resident receives mental health case management. However, the resident?s most recent ISP dated 12-8-21 does not address mental health case management.
Plan of Correction:	Administrator will ensure that all needs on UAI will be addressed on ISP.
Standard #:	22VAC40-73-460-H
Complaint related:	Yes
Description:	Based on a complaint received as well as interviews with the identified residents and staff, the facility failed to ensure, either directly or indirectly, that the health care service needs of residents were met. Evidence: -Resident # 4 had a seizure and fell and hit her head on 1-30-22 and went to the ER where she had staples applied. Resident # 4 was scheduled to return to the doctor to have staples removed from her head within 7 to 10 days, but was not taken back by facility staff for staple removal at the doctor?s office until 19 days later on 2-18-22. -When Staff # 2 was asked about the delay in taking Resident # 4 to have her staples removed, Staff # 2 stated, ?It may have been 16 days. I didn?t see the importance of taking her back right at ten days. I took her back for a TB test and asked the doctor to remove the staples then.? -Staff # 2 stated that Resident # 2 checks his own blood sugar and Staff # 2 will check it with him and Resident # 2 gives himself his insulin. However, resident was hospitalized for two days in ICU for diabetic ketoacidosis due to not receiving his insulin in January 2022. It is noted on a letter from the doctor stating that he feels the resident can self-administer. The resident?s ISP dated 1-21-22 notes ?Assistance with meds. Meds will be given by dr. orders by a certified med tech. There was documentation of resident?s blood sugar readings, but no documentation of facility intervention regarding the blood sugar readings.
Plan of Correction:	Administrator will ensure all follow up care with doctors is taken care of in a timely manner. Administrator will ensure proper insulin will be received in the future.
Standard #:	22VAC40-73-610-B
Complaint related:	No
Description:	Based on observation the facility failed to ensure that a menu for meals and snacks for the current week was dated and posted in an area conspicuous to residents. Evidence: The facility had a dry erase board in the dining area that was not dated and listed cereal, banana, juice for breakfast. There was nothing written on the menu for lunch, and fried chicken was written for ?supper? for the day. When asked if there was a printed menu for the week, Staff # 2 brought a menu that had a date of 6-6-08 scratched through with blue ink and a date of 3-1-02 written in blue ink. Photographic evidence was taken.
Plan of Correction:	Administrator has a new menu template that has been created and will be out Monday mornings when kitchen staff arrive.
Standard #:	22VAC40-73-610-C
Complaint related:	No
Description:	Based on observation the facility failed to ensure that the daily menu, for each resident shall meet the current guidelines of the U.S Department of Agriculture?s food guidance system or the dietary allowances of the Food and Nutrition Board of the National Academy of sciences, taking into consideration the age, sex, and activity of the resident. Evidence: The licensing inspector observed that the lunch meal that residents received did not include a fruit or vegetable and consisted of Vienna sausages with crackers, chips, and cookies with water as the drink. Photographic evidence was taken.
Plan of Correction:	Menu selections will have healthier options to meet the food guidance nutrition system.
Standard #:	22VAC40-73-650-A
Complaint related:	No
Description:	Based on a review of resident records 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. Evidence: -The February 2022 MAR and the physician order sheet for Resident # 2 lists Carbamazepine 200 mg to be administered twice a day at 7:00 a.m. and 7:00 p.m. The February 2022 MAR contains no staff initials to indicate the medication was administered at 7:00 p.m. for the following dates: February 1-28, 2022. There was no documentation in the record that the resident?s physician changes or discontinued the order or that the facility notified the physician that the resident was not taking the medication.
Plan of Correction:	Administrator will ensure all discontinued meds will be pulled and as well as proper dc paperwork from the dr.
Standard #:	22VAC40-73-650-E
Complaint related:	No
Description:	Based on a review of resident records the facility failed to ensure that the resident?s record shall 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. Orders shall be organized chronologically in the resident?s record. Evidence: -The record for Resident # 2 did not contain signed physician?s orders. The record contained Physician?s Order sheets that were not signed. - Staff # 1 stated they will make sure they obtain the signed physician?s orders.
Plan of Correction:	The administrator will ensure all physician orders will get signed in the future.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on a review of resident records the facility failed to ensure that medications shall be administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: -The February 2022 MAR for Resident # 2 lists Carbamazepine 200 mg to be administered twice a day at 7:00 a.m. and 7:00 p.m. However, the MAR contains no staff initials to indicate the medication was administered at 7:00 p.m. for the following dates: February 1-28, 2022.
Plan of Correction:	Administrator will ensure all discontinued meds will be pulled and as well as proper dc paperwork from the dr.
Standard #:	22VAC40-73-680-H
Complaint related:	No
Description:	Based on a review of resident records the facility failed to ensure that at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including the over-the-counter medications and dietary supplements. Evidence: The facility did not have pages 5-7 of Resident # 2?s February 2022 MAR.
Plan of Correction:	Administrator will ensure all pages of the MAR will be in the MAR book during the current month.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on a review of resident records the facility failed to ensure that the medication administration record (MAR) shall include the diagnosis, condition, or specific indications for administering the drug or supplement. Evidence: The MAR for Resident # 2 for February 2022 did not include the diagnosis, condition, or specific indications for administering the drug or supplement for the following medications: Aripiprazole 20 mg, Jardiance 25 mg, Levothyroxine 88 mcg, Ozempic 1mg, Vitamin D3 2000iu, Carbamazepine 200 mg, Gabapentin 600 mg, Lantus Solostar 100 units, Novolog Flexpen Syr 100 u/ML.
Plan of Correction:	The Administrator has contacted the pharmacy to get all the diagnosis added to the next set of MAR?s received.