VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cave Creek ALF
8088 Lee Highway
Troutville, VA 24175
(540) 992-4599

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: Oct. 25, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/25/2022 at 8:45am until 1:45pm 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: 26 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-200-B
Description:	Based on a review of resident records and staff interviews, the facility failed to ensure that direct care staff who are responsible for caring for residents with special health care needs only provided services within the scope of their practice and training. EVIDENCE: 1. The record for resident 2 has a physician order dated 02/04/2022 for a transparent dressing apply as directed every day, apply over gauze pad to wound/lower back. The October 2022 medication administration record (MAR) for resident 2 has RMA staff initials for the completion of this treatment daily from 10/01/2022 through 10/25/2022. An interview with staff person 1 expressed that sometimes they cleanse the wound with Hydrogen Peroxide and apply Triple antibiotic ointment and that it just depends on what the area looks like. This wound care in not in the scope of practice for a RMA.
Plan of Correction:	The affected area is actually a ?Mole? and not a ?Wound? Physician will change wording on the Order to reflect accurate description. Staff was instructed to care for the mole as directed.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review and staff interview, the facility failed to ensure within the 30 days preceding admission, a person had a physical examination by an independent physician. EVIDENCE: 1. Resident 4 was admitted to the facility on 07/27/2022; however, the record for the resident contained three reports of resident physical examinations for the resident that were dated 05/16/2022, 08/17/2022 and 09/28/2022. Interview with staff 4 confirmed the required report of resident physical examination was not completed on the resident within 30 days preceding admission to the facility.
Plan of Correction:	Resident #4 was transferred from its sister facility. The administrator will ensure H&Ps are completed with 30 days for future transfers.
Standard #:	22VAC40-73-350-B
Description:	Based on resident record review and staff interview, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. EVIDENCE: 1. Resident 4 was admitted to the facility on 07/27/2022; however, the facility did not conduct a registered sex offender search prior to the resident being admitted to the facility. Interview with staff 4 confirmed there was no registered sex offender search conducted for the resident prior to their admission.
Plan of Correction:	The administrator will do a new registered sex offender search before transfers from sister facility or new admissions. A search was conducted.
Standard #:	22VAC40-73-640-A
Description:	Based on observations of the facility medication, review of the facility medication management plan and interviews with staff, the facility failed to implement their medication management plan in regards to methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The LI requested to review the narcotic count log and noted that there was no documentation of a narcotic count at shift change. An interview with staff person 1 expressed that narcotics are not counted with on-coming and out-going shifts. The facility medication management plan has documentation of the following; ?Controlled substances must be counted at the end of each shift and documented by two med-aides.
Plan of Correction:	The facility medication management plan was updated to include the Charge DCA at end of shift count.
Standard #:	22VAC40-73-870-A
Description:	Based on observation during a tour of the facility?s physical plant, the facility failed to ensure the interior of the building was maintained in good repair and kept clean. EVIDENCE: 1. One licensing inspector (LI) noted that the window air conditioning unit in room 9?s bathroom was plugged into a power strip. 2. The shower curtains located in bathrooms 23 and 24 contained multiple stains along the bottom of each curtain. 3. In room 26 the flooring and heater baseboard around the toilet in bathroom contained areas of dust and dirt and the shower mat in the bath tub was dirty.
Plan of Correction:	Power strip removed immediately. Curtains were immediately removed and all areas thoroughly cleaned
Standard #:	22VAC40-73-870-E
Description:	Based on observation during a tour of the facility?s physical plant, the facility failed to ensure bathtubs were kept clean and in good repair and condition. EVIDENCE: 1. During on-site inspection on 10/25/2022, one licensing inspector (LI) observed that the bathtubs in rooms 24 and 25, which were occupied by residents, contained multiple areas of staining around the drain and multiple areas of a peeling substance throughout the two bathtubs.
Plan of Correction:	Bathtubs will be repaired.
Standard #:	22VAC40-73-880-B
Description:	Based on observation during a tour of the facility?s physical plant and staff interview, the facility failed to ensure the operation of space heaters was approved by the state or local building or fire authorities. EVIDENCE: 1. At approximately 8:59AM during on-site inspection on 10/25/2022, two licensing inspectors (LIs) noted in room 19 a space heater that was on in the resident?s room. Interview with the resident in room 19 revealed that he uses the space heater to keep warm. Staff 4 did not have documentation to provide during the on-site inspection that the state or local building or fire authorities had approved the use of space heaters.
Plan of Correction:	Heater was removed from room. The resident was transferred to another room until heating is repaired.
Standard #:	22VAC40-73-890-B
Description:	Based on observation during a tour of the facility?s physical plant, the facility failed to ensure all interior areas were adequately lighted for the safety and comfort of residents and staff. EVIDENCE: 1. During on-site inspection on 10/25/2022, one licensing inspector (LI) noted that the light in the bathroom in room 26 was not operable. Room 26 is occupied by a resident.
Plan of Correction:	Light bulb was replaced