VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Dunlop House
235 Dunlop Farms Boulevard
Colonial heights, VA 23834
(804) 520-0050

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Oct. 18, 2022 and Oct. 20, 2022

Complaint Related: No

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/18/2022 11:12 a.m -2:15p.m. 10/20/2022 10:12a.m - The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 97 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: 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. 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 #:	22VAC40-73-440-H
Description:	Based on the review of facility records the facility failed to ensure that annual reassessments and reassessments due to a significant change in the resident's condition, using the UAI, was utilized to determine whether a resident's needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: Resident #6 Documented date of admission 02/07/2020 The resident?s most recent 06/27/2022 UAI assessed the resident as needing no assistance with eating/feeding. The facility?s Weight document charting for July, August and September 2022 and the facility?s 09/20/2022 Nutritional Consultation Concerns and Recommendations document that was submitted for the inspector?s review indicates weight loss as a problem. Based on the facility?s documented weights and the concerns noted by the nutritionist the facility did not reassess the resident to determine whether appropriate adjustments regarding the resident?s dietary consumption is needed and whether the resident?s needs can continue to be met by the facility.
Plan of Correction:	FACILITY'S RESPONSE: " During 7 month period from April 2022 to November 2022 resident?s weights have fluctuated within 7 pounds of 141.0 both up and down. Residents weight remains stable. All resident weights are reviewed at least monthly, and any 5% gain/loss is followed up on. Effective 11/1/2022"
Standard #:	22VAC40-73-450-C
Description:	Based on the review of facility records the facility failed to ensure that the comprehensive individualized service plan was completed within 30 days after admission. Resident #7 Documented date of admission 03/31/2022 The most recent ISP that was submitted for the inspector?s review is dated 03/24/2022. Upon request the facility did not submit documented evidence that a comprehensive ISP has been developed for resident #7.
Plan of Correction:	FACILITY'S RESPONSE: "Facility completed the comprehensive service plan 7 days prior to admission. Facility will review all service plans for new admissions at 30 days and document no changes or will revise service plan accordingly. Effective 11/1/2022"
Standard #:	22VAC40-73-450-E
Description:	Based on the review of facility records the facility failed to ensure that the individualized service plan (ISP) is 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 #3 ISP dated 10/13/2022 Resident #4 ISP dated 10/13/2022 Resident #6 ISP dated 06/27/2022 Resident #8 ISP dated 07/07/2022 The residents? ISPs that were submitted for the inspector?s review did not note the signature for residents or the legal representative(s) signature.
Plan of Correction:	FACILITY'S RESPONSE: "All service plans for new admissions will be signed by administrator or designee and by the resident or legal representative. Effective 11/1/2022. Existing service plans will be audited for signatures and signed by the above parties. Effective 2/1/2023"
Standard #:	22VAC40-73-450-F
Description:	Based on the review of facility records the facility failed to ensure that the individualized service plans (ISP) were updated as needed for a significant change of a resident?s condition. The review and update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons. Evidence: Resident #6 Documented date of admission 02/07/2020 The facility?s Weight documented that was submitted for the inspector?s review noted the following weights for resident #6: 07/01/2022: 145.1 lbs. 08/01/2022: 140.2 lbs. 09/01/2022: 134 lbs. The facility?s Nutritional Consultation Concerns and Recommendations document dated 09/20/2022 notes under the heading Problem: ?wt. loss? and recommends that the resident is to be offered ?snacks/shakes?. The resident?s 06/27/2022 ISP notes in part under the heading Eating/Feeding ?snacks and fruit available throughout the day?. The resident?s 06/27/2022 ISPs was not updated to identify that based on the concerns and recommendation of the Nutritionist regarding the resident?s weight loss -snacks and fruit are now a dietary need for the resident rather than being available. Resident #7 Documented date of admission 03/31/2022 The resident?s 03/24/2022 ISP notes that the resident feeds self but needs supervision and physical cueing to complete a meal and that facility staff are to report changes in the resident?s participation in eating/feeding. Facility documentation submitted for the inspector?s review noted significant weight loss beginning 07/01/2022 until 10/04/2022. The resident?s 03/24/20222 ISP was not updated to identify appropriate adjustments regarding staff?s responsibility and guidance for facility staff to implement to address the resident?s ongoing weight loss.
Plan of Correction:	FACILITY'S RESPONSE: "Both residents? weights are stable. All service plans will be updated upon any change in condition. 11/1/2022"
Standard #:	22VAC40-73-620-B
Description:	Based on the review of facility records the facility failed to ensure that the nutritionist oversight was conducted as required. Evidence: The facility?s most recent Nutritional Consultation Concerns and Recommendations document dated 09/20/2022 is not documented to clarify that an evaluation of the adequacy of the resident's special diet and the resident's acceptance of the diet.
Plan of Correction:	TFACILITY'S RESPONSE: "he dietician did not have this specific concern; dietician will document this in writing during their quarterly evaluations. 2/1/2022"
Standard #:	22VAC40-73-660-B
Description:	Based on observation the facility failed to ensure that a resident who has not been assessed as independent in medication administration was permitted to keep medication in the room. Evidence: Resident #2 Documented date of admission 06/11/2018 10/18/2022: As evidenced by the photographs taken during the mid-morning medication administration pass with facility staff #3 over the counter medications were observed in the resident?s bathroom medication cabinet. The most recent 03/15/2022 UAI assessment that was submitted for the inspector?s review assessed the resident as being dependent on qualified facility staff to administer her medications.
Plan of Correction:	FACILITY'S RESPONSE: "Resident family brought over the counter medicines into the room. All resident rooms were re-assessed regarding whether medications are present. All are safe and compliant. Effective 10/18/2022. Family education will be made during admission process regarding over-the-counter medicines. Effective 10/18/2022"