VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Elance at Old Town
400 N.Washington Street
Alexandria, VA 22314
(703) 236-1226

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: Nov. 3, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A complaint was received by VDSS Division of Licensing on 10/27/2022 regarding allegations in the areas of resident care and activities. Licensing Inspector (LI) conducted unannounced complaint investigation on 11/3/2022. LI reviewed resident record, activity schedules and staff training. Spoke with Executive Director. Complaint is deemed valid as a preponderance of evidence gathered during the investigation supported the allegations. An exit meeting was 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 Lynette Storr, Licensing Inspector at (703) 479-4708 or by email at lynette.storr@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-325-A
Complaint related:	Yes
Description:	Facility failed to ensure that for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating shall be completed. Evidence: Based on interview and documentation review Resident #1 meets the criteria for assisted living care and does not have a completed fall risk rating in the resident record.
Plan of Correction:	No documented negative outcome. Resident moved into another Memory Care Community. RCD or designee to complete chart audits to ensure all residents have fall assessment done. ED reviewed violations with leadership team and conducted a refresher meeting. Team will continue to meet weekly to verify any new falls have a fall assessment rating done. During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the Executive Director will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
Standard #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	The facility failed to ensure that the comprehensive individualized service plan includes a written description of all services that will be provided to address identified needs. Evidence: Based on documentation review and interview, Resident #1's most recent individualized service plan does not include his assessed need for skin care. Throughout the nurse's notes it indicates that the resident has various skin issues including dry, flaky skin, scratches and wounds on his face, arms, buttocks and behind his ear. The specialized care required for these issues is not documented on the individualized service plan.
Plan of Correction:	No documented negative outcome. Resident moved into another Memory Care Community RCD or designee to complete chart audits to verify service plans address identified needs. ED reviewed violations with leadership team and conducted a refresher meeting. Team will continue to meet weekly to verify new identified needs are added to the service plan. During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the Executive Director will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices
Standard #:	22VAC40-73-480-A
Complaint related:	Yes
Description:	Facility failed to ensure that all restorative care and habilitative service needs of the residents are met. Evidence: Resident #1's admission physical dated 1/5/2022 indicated a need for speech therapy by the primary care physician. Based on interview and documentation review, speech therapy services were not provided or arranged for by the facility.
Plan of Correction:	No documented negative outcome. Resident moved into another Memory Care Community RCD or designee to complete chart audits to verify all habilitative services documented at admission have been addressed. ED reviewed violations with leadership team and conducted a refresher meeting. Team will continue to meet weekly to verify new habilitative service needs are being met. During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the Executive Director will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
Standard #:	22VAC40-73-560-E
Complaint related:	Yes
Description:	Facility failed to ensure that the resident record is kept current. Evidence: Based on documentation review and interview, Resident #1's record was not kept current. The review of the resident record included a reference to a dermatological ear procedure on 5/7/2022. There is no documentation regarding the actual procedure or follow up care instructions. Additionally, there is a reference to a podiatry appointment on 2/2/2022 however there is no documentation regarding the outcome of that appointment.
Plan of Correction:	No documented negative outcome. Resident moved into another Memory Care Community. RCD or designee to complete chart audits to verify the resident?s records are kept current. ED reviewed violations with leadership team and conducted a refresher meeting. Team will continue to meet weekly to verify resident records are kept current. During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the Executive Director will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	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 registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Resident #1 has a physician's order dated 1/13/2022 for Mertazapine 45mg once a day. Based on review of the resident's April medication administration record, the resident did not receive this medication from April 1, 2022 - April 7, 2022.
Plan of Correction:	No documented negative outcome. Resident moved into another Memory Care Community. RCD or designee to complete Audit off resident medication orders to ensure they are being administered in accordance with the physician?s or other prescriber?s instructions. ED reviewed violations with leadership team and conducted a refresher meeting. Team will continue to meet weekly to verify resident medications are being administered in accordance with physicians orders. MCM?s will conduct med cart audits weekly and RCD will conduct med cart audits monthly for 3 months. For up to 3 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results of the audits and determine if additional focus or action is warranted