VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lillian's Loving Care
3736 Turnpike Road
Portsmouth, VA 23701
(757) 393-9241

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: May 16, 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 63.2 GENERAL PROVISIONS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 05/16/2023 at 8:15 am to 3:00 pm. 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: 11 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: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-D
Description:	Based on the staff record review the facility failed to ensure training for medication aides include continuing education required by the Virginia Board of Nursing, Evidence: 1. The Regulations Governing the Registration of Medication Aides by Virginia Board of Nursing, section 18VAC90-60-100-B, state that a medication aide shall have four hours each year of population-specific training in medication administration in the assisted living facility in which the aide is employed; or a refresher course in medication administration offered by an approved program 2. The record for staff #1, a registered medication aide, hire date 12/20/19, did not contain documentation of the staff completing the required annual continuing education or a refresher course in medication administration for the dates of 12/20/19 to 05/16/23. 3. The record for staff #2, a registered medication aide, hire date 05/15/19, did not contain documentation of the staff completing the required annual continuing education or a refresher course in medication administration for the dates of 05/15/19 to 05/16/2023. 4. The record for staff #3, a registered medication aide, hire date 08/15/14, did not contain documentation of the staff completing the required annual continuing education or a refresher course in medication administration for the dates of 08/15/14 to 05/16/23.
Plan of Correction:	The facility will ensure that staff training for Medication Aides will include continuing education as required by the Virginia Board of Nursing.
Standard #:	22VAC40-73-450-C
Description:	Based on the record review the facility failed to ensure the comprehensive individualized service plan (ISP) shall include the following: identified needs based upon the Uniform Assessment Instrument (UAI), and other sources. Evidence: 1. Resident?s #2 UAI dated 11/28/22 documents a response of Yes for Allergies. The resident?s Physician note dated 02/21/19 documents the resident is allergic to Penicillin V Potassium and Peanut Butter Products. The resident?s ISP dated 03/01/2023 did not include the needs to address the resident?s Penicillin V Potassium and Peanut Butter allergies.
Plan of Correction:	The facility will make sure that the Comprehensive Individualized Plan (ISP) will identify and include the needs based upon the Uniform Assessment Instrument (UAI), and other sources.
Standard #:	22VAC40-73-640-A
Description:	Based on observation the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated medications. Evidence: 1. During observation of the medication cart with staff #3, the following expired medication was located on the medication cart: Simvastatin 20 mg expired 07/31/22.
Plan of Correction:	The facility will make sure to implement the written plan in medication management the methods to prevent the use of outdated medication.
Standard #:	22VAC40-73-860-G
Description:	Based on observation the facility failed to ensure the hot water at taps available to residents shall be maintained within a range of 105?F to 120?F. Evidence: 1. During the onsite inspection, the water temperature in the women?s shared bathroom was measured 97.0 degrees F. The water temperature in the common area bathroom was measured to 96.6 degrees F.
Plan of Correction:	The facility will make sure that hot water taps are available to the residents and shall be maintain within a range of 105?F to 120?F.