VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Fork Mountain Adult Home
2925 Fork Mountain Road
Rocky mount, VA 24151
(540) 483-8800

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

Inspection Date: May 1, 2023

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: 05/01/2023 8:45am until 1:30pm 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: 18 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 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 #:	22VAC40-73-310-D
Description:	Based on resident record reviews, the facility failed to ensure that written assurance that the facility has the appropriate license to meet their care needs was provided to the resident prior to their admission to the facility. EVIDENCE: 1. The record for resident 3, admitted on 02/20/2023, did not contain documentation that the resident had received a written assurance prior to their admission to the facility.
Plan of Correction:	Documentation put in all charts and family notified
Standard #:	22VAC40-73-325-B
Description:	Based on resident record review and staff interview, the facility failed to ensure that fall risk ratings are reviewed and updated at least annually, when the condition of a resident changes and after a fall. EVIDENCE: 1. The private pay uniform assessment instrument (UAI) for resident 2, with a reassessment date of 12/27/2022, and the public pay UAI for resident 4, dated 06/22/2022, indicate that residents 2 and 4 are assisted living level of care. During on-site inspection on 05/01/2023, the records for residents 2 and 4 did not contain fall risk ratings. Interview with staff 1 confirmed that this was accurate. 2. The UAI dated 02/20/2023 in the record for resident 3 has the resident assessed as assisted living level of care. The record for resident 3 has documentation that the resident fell on 03/11/2023 and was sent to the local emergency room for evaluation. The record for resident 3 did not contain documentation of a fall risk rating being completed after this fall.
Plan of Correction:	Fall risk rating has been updated.
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. The record for resident 3, admitted on 02/20/2023, did not contain documentation that a sex offender screen was completed for this resident prior to or at the time of their admission to the facility. 2. Resident 4 was admitted to the facility on 07/07/2022. The record for the resident did not contain documentation that a sex offender search with the Virginia State Police had been completed on the resident. Interview with staff 1 confirmed that this is accurate.
Plan of Correction:	Sex Offender screening has been documented for both residents.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review, the facility failed to ensure that a uniform assessment instrument (UAI) for a resident was completed as required. EVIDENCE: 1. The UAI for resident 2, with a reassessment date of 12/27/2022, did not contain the assessor?s name, the assessor?s signature, the agency/assisted living facility name and the date of the assessment and also did not include the administrator or designee?s signature, title and the date of the assessment.
Plan of Correction:	UAI was completed, signed and dated.
Standard #:	22VAC40-73-450-D
Description:	Based on resident record review, the facility failed to ensure the individualized service plan (ISP) for a resident who receives hospice care contains the services that hospice is providing. EVIDENCE: 1. The record for resident 1 contained documentation that the resident is receiving hospice services for wound care and has a medical social worker from the hospice agency; however, the resident?s ISP, with a review date of 12/27/2022, does not include these hospice provided services.
Plan of Correction:	Resident 2 is the resident in question and services were put on ISP and corrected.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review, the facility failed to ensure that individualized service plans (ISPs) were signed and dated by the resident or his legal representative. EVIDENCE: 1. The ISP for resident 1, with a resident date of 05/27/2022, is not signed and dated by the resident or their legal representative. 2. The ISP for resident 2, with a review date of 12/27/2022, is not signed and dated by the resident or their legal representative. 3. The ISP for resident 3, dated 02/20/2023, is not signed and dated by the resident or their legal representative. 4. The ISP for resident 4, dated 07/07/2022, is not signed and dated by the resident or their legal representative.
Plan of Correction:	Documentation was signed by their representative and resident. All signed and dated.
Standard #:	22VAC40-73-620-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that a oversight for residents with special diets was completed every six months by a dietician or nutritionist. EVIDENCE: 1. The records for residents 9 and 10 have documentation that these residents are prescribed special diets, which was confirmed by staff 1. Per an interview with staff 1 it was expressed that an oversight of special diets by a dietician or nutritionist has not been completed in the past six months.
Plan of Correction:	In the process of getting diet changed to a regular diet.
Standard #:	22VAC40-73-640-A
Description:	Based on facility policy review and staff interview, the facility failed to implement a section of its medication management plan. EVIDENCE: 1. The facility?s medication management plan provided on day of inspection indicates that when assigned medication administration staff changes that the facility will use a controlled substance count sheet for each resident that is given a controlled substance to ensure accurate counts of all controlled substances. 2. During on-site inspection on 05/01/2023, the facility?s medication cart contained controlled substances for resident 1 (Lorazepam), resident 3 (Oxycodone), and resident 6 (Lorazepam), however; there were no controlled substance count sheets for these medications. Interview with staff 1 confirmed that this is accurate.
Plan of Correction:	All controlled medications have daily count sheets.
Standard #:	22VAC40-73-650-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment was started, changed, or discontinued without a valid order from a physician or other prescriber. EVIDENCE: 1. The record for resident 2 contained the following documentation: a staff note, dated 03/29/2023 at 5:00PM, that the resident has a blister on his right heel and for staff to keep an eye on it; a staff note written by staff 2, dated 03/30/2023 at 9:00AM, that staff 2 had cleaned and dressed the resident?s heel because the blister had busted and was draining and for facility staff to continue to watch the blister on the resident?s heel; a staff note written by staff 2, dated 04/01/2023 at 12:00PM, that the resident?s heel is still being cleaned and dressed; and a staff note written by staff 2, dated 04/15/2023 at 9:25AM, that staff person 2 had contacted hospice about the resident?s heel not responding to the facility?s treatment and that the resident possibly needs antibiotics; hospice informed staff person 2 that hospice would be contacting the resident?s physician. A note written by staff 2, dated 04/16/2023, indicated that hospice brought the resident antibiotics on this date. 2. The record for resident 2 did not contain a physician?s order for wound care that was provided to the resident?s heel until 04/20/2023 when a physician order was written to clean with wound cleanser, pat dry with gauze, cover with xeroform and 4x4?s, cover with rolled gauze and change every other day by skilled nursing or facility staff. The record also contained an additional physician?s order, dated 04/24/2023, for Flagyl 500MG to be crushed and placed as a topical into the resident?s wound daily for 10 days.
Plan of Correction:	Staff has been informed not to provide wound care. Hospice will be changing dressing 3x a week.
Standard #:	22VAC40-73-680-F
Description:	Based on observation during medication cart audit, resident record review and staff interview, the facility failed to ensure that sample medications remain in the original packaging, labeled by a physician or other prescriber or pharmacist with the resident?s name, the name of the medication, the strength, dosage, and route and frequency of administration, until administered. EVIDENCE: 1. During an audit of the facility?s medication cart, one licensing inspector (LI) noted an amber colored bottle with a blue top that contained the following written in black marker: Eliquis 2.5MG BID. 2. Interview with staff 1 revealed that the medication is for resident 7. The record for resident 7 contains a physician?s order, dated 03/31/2023, for Eliquis 2.5MG two times a day. Interview with staff 1 revealed that the medication came from a free clinic and confirmed that the bottle did not contain all required information.
Plan of Correction:	Staff has reported to the resident's POA (daughter) that we are to have labeled bottles for her medication so that she needs to provide the medicine that is needed. APS is working on the situation with the resident's POA.
Standard #:	22VAC40-73-680-H
Description:	Based on resident record review and staff interview, the facility failed to document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements, at the time the medication is administered. EVIDENCE: 1. At approximately 11:10AM during on-site inspection, it was noted by one licensing inspector (LI) and staff 2 that the facility?s MAR binder did not contain a MAR for resident 8. 2. At approximately 11:20AM, staff 2 produced a May 2023 MAR for resident 8 that had been printed off the facility?s computer. The May 2023 MAR contained documentation that the resident receives the following medications daily at 7:00AM: Losartan 25MG, Pravastatin 20MG, Cetirizine 10MG and Seroquel 50MG. The May 2023 MAR provided by staff 2 did not contain staff initials that these medications had been administered to the resident at 7:00AM on day of inspection. Staff 1 revealed that the medications were administered to the resident but that the staff person that had administered the medications did not have the May 2023 MAR yet in order to initial that they had administered to the resident.
Plan of Correction:	This was corrected on 5/1/2023. Staff 1 was in the process of a new cycle of medication record paperwork when the state arrived.
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the building, the facility failed to ensure that chemicals and other hazardous materials were stored in a locked area. EVIDENCE: 1. At approximately 9:04AM during on-site inspection on 05/01/2023, it was noted by one licensing inspector (LI) that the door to resident 8?s room was unlocked and unattended. In the far back corner of the resident?s room contained an unlocked closet that contained the following cleaning supplies: spray containers of Lysol disinfectant spray, spray bottles of Great Value cleaner of bleach and spray bottles of SE-500 odor eliminator. Interview with staff 1 revealed that the cleaning items in the closet are the facility?s cleaning supplies used by facility staff.
Plan of Correction:	The cabinet in question has been locked with a padlock to ensure safety of residents.
Standard #:	22VAC40-90-40-B
Description:	Based on a review of staff records, the facility failed to ensure that a criminal history record report was obtained on all employees on or prior to the 30th day of employment. EVIDENCE: 1. The record for staff 4, hired on 01/28/2023, did not contain documentation that a criminal history record report was obtained on this employee.
Plan of Correction:	Background check was sent to the wrong address but it has been acquired.