VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Emily Green Shores
500 Westmoreland Avenue
Portsmouth, VA 23707
(757) 399-3442

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: March 20, 2023

Complaint Related: Yes

Areas Reviewed:

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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 03/20/2023 at 8:17 am to 12:50 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/09/2022 regarding allegations in the areas of: Personnel, Resident Care and Related Services, 28 Number of residents present at the facility at the beginning of the inspection: 28 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Breakfast was observed, and a medication pass observation was completed for one resident. The following documents were reviewed: staffing schedule, resident council meeting minutes, and staff training records. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations area of non-compliance with standard(s) or law were issued.: A violation notice was issued; any violation(s) not related to the complaint) but identified during the course of the investigation can also be found on the violation notice. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-200-B
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure direct care staff who are responsible for caring for residents with special health care needs shall only provide services within the scope of their practice and training. Evidence: 1. Staff #1 acknowledged that on 02/27/23, staff #3 a certified nurse?s aide, removed and placed the condom catheter for resident #1. 2. Placement and removal of a condom catheter is outside the scope of practice for a certified nurse assistant.
Plan of Correction:	Administrator verbally instructed direct care staff to follow orders and to practice only within the scope of their practice and training and follow physician?s orders to ensure the safety and wellbeing of all residents.
Standard #:	22VAC40-73-460-A
Complaint related:	Yes
Description:	Based on the record review the facility did not assume responsibility for the health, safety, and well-being of resident #1. Evidence: 1. The record for resident #1 contains a note dated 02/27/23 by the hospice nurse to include ?patient?s condom catheter was applied tightly causing an unstageable pressure ulcer.? 2. A physician order dated 02/27/23 documents ?wound care-penile- cleanse with wound cleaner, pat dry, apply calmoseptine daily and as needed.? 3 Staff #1 confirmed during an interview with this inspector on 03/20/2023 that staff #3, a certified nurse assistant, applied the condom catheter tightly, which resulted in the resident?s need for penile wound care.
Plan of Correction:	Administrator reiterated verbally and in writing the importance of following physician?s orders and practicing within the scope of practice and training with all direct care staff to ensure the safety and wellbeing of all residents.
Standard #:	22VAC40-73-680-E
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. The documentation shall be maintained in the resident?s record. Evidence: 1. The record for resident #1 contains a physician order dated 01/11/2023 which includes instructions to reposition the resident in bed every 2-3 hours. The resident?s record and medication administration record (MAR) for January, February, and March 2023 did not include documentation the resident is repositioned in bed every 2- 3 hours. 2. The record for resident #1 contains a physician order dated 01/24/2023 to include the following instructions: ?apply skin prep to reddened area of sacrum area daily with AM care? and ?apply barrier ointment to reddened area of sacrum twice a day in the afternoon and bedtime.? The resident?s record and MAR did not include documentation skin prep was applied to the reddened area of the sacrum on the following dates: 02/18/23; 02/19/23; 02/24/23. The resident?s record and MAR did not include documentation barrier ointment was applied to the reddened area of sacrum twice a day in the afternoon and bedtime on the following dates and times: 02/01/23-02/03/23 at 8pm; 02/06/23-02/09/23 at 8pm; 02/11/23-02/12-23 at 8pm; 02/18/23-02/19/23 at 12pm; 02/23/23-02/24/23 at 12pm. 3. The record for resident #1 contains a physician order dated 02/27/23 that include instructions to ?change resident every 2 hours to ensure he is dry.? The resident?s record and MAR did not include documentation the resident is changed every 2 hours.
Plan of Correction:	Resident Care Coordinator will monitor to ensure that the medication aides are following written physician?s orders as instructed and documenting at time treatment is completed. A scheduled turn and check for incontinence chart will be kept in Resident?s room and initialed by the direct care staff at time of scheduled turn/repositioning and continence check then file in Resident?s chart monthly as completed.