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Assisted Living at Lucy Corr
6800 Lucy Corr Boulevard
Chesterfield, VA 23832
(804) 748-1511

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: Oct. 3, 2022

Complaint Related: No

Areas Reviewed:
X 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS

Comments:
Facility Name: AL at Lucy Corr
File #: 1052253
Inspection Date:10/3/2022
Inspection End Date: 10/3/2022

The facility self reported an incident to VDSS Division of Licensing on 98/4//22 regarding an incident in the area of Resident Care and Related Services;
Resident records reviewed: 1 remotely
Number of staff records reviewed: 0
Number of interviews conducted with residents: O
Number of interviews conducted with staff: 1

Additional Comments/Discussion: An on-line complaint was received later regarding the same incident. The on-site inspection on 10/3/22 was terminated due to potential COVID exposure.

The evidence gathered during the inspection did not determine non-compliance with applicable standards or law.

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 will be 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 #: 22VAC40-73-680-D
Description: Based on a review of physician orders, and medication administration records and progress
notes, medication was not administered in accordance with the physician instructions for
one resident (Resident # 1).

Evidence:
Progress notes document the following:
1. 8/3/22 at 21:44 (9:44 pm) - " Resident expresses pain in her left hip/thigh".
2.. 8/3/22 at 21:54 (9:54 pm) - "MD ordered Tylenol 650mg Q6 for pain".
3. 8/4/22 at 11:16 "xray ordered for left hip pain and swelling."
4. 8/4/22 at 19:19 (7:19 pm) - "Resident sent to ER per MD order due to pain and inability to
ambulate ".

The medication administration record (MAR) for resident # 1 document a start date of 8/3/22 and a start time of 2200 (10 pm) for Tylenol 650mg Q6 for pain. The only documented
administration of Tylenol from 8/3/22 at 10 pm to 8 /4/22 at 7:19 pm is on 8/4/22 at 6:13 am.

Plan of Correction: The Assisted Living Administrator and/or Clinical Nurse Manager, or their designee, will in-service and educate all assisted living staff and/or licensed to administer medications in accordance with physician instructions, as well as instruct staff on documentation best practices. This will be completed by 10/19/2022.
The Clinical Nurse Manager and/or Assisted Living Administrator , or their designee, will review the "24 Hour" report each morning for accurate documentation and any medication documentation discrepancies beginning 10/7/22.
The Assisted Living Manager and or Clinical Nurse Manager, or their designee, will continue to conduct monthly educational inservices with all assisted living staff, certified and/or licensed, to administer medications, on administering medications in accordance with physician instructions, as well as instruct staff on documentation best practices beginning in November 2022.

Standard #: 22VAC40-73-680-I
Description: Based on a review of the August 2022 medication administration record (MAR) for one resident, medication administered was not accurately documented on the MAR.

Evidence: Progress notes for resident # 1 document the following:
1. 8/4/22 at 1740 - Resident sent out to ER
2. 8/5/22 at 19:49 - Resident in hospital.

Medications documented on the MAR as administered by staff while resident was in the hospital.

Plan of Correction: The Clinical Nurse Manager and/or Assisted Living Administrator, or their designee, will review the "24 Hour" report each morning for accurate documentation and any medication documentation discrepancies beginning 10/7/22.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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