VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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Current Inspector:

Inspection Date: Nov. 14, 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(s) of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 11/14/2022 9:30AM through 2:30PM 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: 19 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: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: activities, medication pass, noon-time meal 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-550-G
Description:	Based on resident record review and staff interview, the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities were reviewed annually with each resident. EVIDENCE: The records for residents 5 and 6 contained documentation that resident 5 has not had an annual review of rights and responsibilities since 2019 and resident 6 since 2020. Interview with staff 2 confirmed this information is accurate.
Plan of Correction:	Administrator reviewed resident rights with resident 5 and 6 and obtained signatures. Admin. will check more carefully in oversight to ensure the policy to review is followed.
Standard #:	22VAC40-73-640-A
Description:	Based on an audit of the facility?s medication cart, the facility failed to implement a component of its medication management plan. EVIDENCE: 1. The facility?s medication management plan states the following: ?Controlled drugs are counted every shift by the LPN or RMA on duty and any discrepancies are reported to the Administrator immediately upon discovery.? At approximately 9:55AM during the medication cart audit, the controlled drug sheet for resident 7?s scheduled Alprazolam 0.25MG indicated that there were 22 doses remaining of the medication; however, there were only 19 doses accounted for in the two medication cards. Interview with staff 1 and 2 verified this was accurate. During on-site inspection on 11/14/2022, the controlled sign off sheet indicated that the last count of narcotics was completed on 11/11/2022. 2. The facility?s medication management plan indicates that the LPN checks medications twice weekly for any outdated, damaged or contaminated medications. The medication cart contained an opened Insulin Glargine (Lantus Solostar) pen for resident 4 that did not contain an open date. The manufacturer?s instructions for the aforementioned insulin indicates that the insulin is only good for 28 days once opened.
Plan of Correction:	Administrator will give a training review to all med aides on the documenting of dates on newly opened medication and which medications require it. All staff administering medications will review the facility's medication administration policy. Administrator will also review with staff the controlled drug count procedure. The Administrator found the error during inspection which was clerical and all drugs were accounted for.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to ensure medications were administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: The record for resident 3 contained a physician?s order, dated 09/09/2022, for Hydralazine 25 MG take one tablet by mouth every day only if systolic (top number) blood pressure is over 130. The October 2022 medication administration record (MAR) for the resident indicates that the aforementioned medication was administered to the resident; however, the resident?s blood pressure was 128/63.
Plan of Correction:	The administrator will be sure that the proper documentation was completed. The medication was held but the "not given" button was not pushed when finalizing the med pass. B/P was taken and noted and staff knows the med was in fact held.
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the building, the facility failed to ensure that cleaning supplies and other hazardous materials are stored in a locked area. EVIDENCE: At approximately 9:39 AM during on-site inspection, one licensing inspector (LI) observed that the door to the laundry room was propped open. Upon entry to the room, the LI observed numerous cleaning supplies, a housekeeping cart with cleaning supplies, and an open container of Tide powder laundry detergent.
Plan of Correction:	The administrator placed a sign on the utility room door stating it had to be closed at all times and could not be propped open and a memo was sent to all staff.
Standard #:	22VAC40-73-870-E
Description:	Based on observation during a tour of the building, the facility failed to ensure that all furnishings, fixtures, and equipment were kept clean and in good repair and condition. EVIDENCE: At approximately 9:50 AM during on-site inspection, one licensing inspector (LI) observed that the fluorescent light coverings outside of room 7 and room 14 appeared to have numerous dark spots inside.
Plan of Correction:	The maintenance staff were notified to clean the fixtures and a cleaning schedule put in place to check them to ensure they are kept clean.