VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Town Creek Assisted Living Facility
393 Front Street
Lovingston, VA 22949
(434) 263-4313

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

Inspection Date: May 17, 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: 05/17/2023 9:00am until 3:00pm 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: 57 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 13 Number of staff records reviewed:7 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 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 #:	22VAC40-73-100-C-1
Description:	Based on observations of the facility medication carts and policy review, the facility failed to implement their infection control policy regarding blood glucose monitoring practices that are consistent with CDC recommendations. EVIDENCE: 1. Section 5 of the facility?s infection control policy regarding glucose monitoring states that multi-dose insulin vials, finger stick capillary blood sampling devices, lancets and glucometers are assigned to individual residents, are labeled appropriately and are to be used only by that resident. 2. At approximately 9:46AM during on-site inspection, one licensing inspector and staff 2 noted that the glucometers in medication cart A for residents 10, 11, 12 and 13 were not labeled with the residents? name.
Plan of Correction:	Glucometers have been labeled with resident?s name.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure that individualized service plans (ISPs) were completed as required. EVIDENCE: 1. The ISP for resident 4, with a review date of 12/09/2022, indicates that the resident is receiving physical therapy services; however, the record for the resident contains documentation that the resident was discharged from physical therapy on 01/10/2023. Interview with staff 5 confirmed this is accurate and the ISP should be updated to reflect that the resident no longer receives physical therapy. 2. The history and physical dated 01/09/2023 in the record for resident 3 has documentation that the resident sustained a fall with a right hip fracture and is a fall risk. The ISP dated 01/13/2023 in the record for resident 3 does not address this identified need.
Plan of Correction:	ISP for Resident 4 has been updated to reflect that PT has been stopped. ISP for resident 3 has been updated to reflect past histories of falls.
Standard #:	22VAC40-73-640-A
Description:	Based on observations of the facility medication carts and policy review, the facility failed to implement a portion of its medication management plan. EVIDENCE: 1. The facility?s medication management plan indicates on page 2 that medication administration staff are to ensure that medications are not outdated and on page 26 that any insulin more than twenty-eight days old, is to be disposed of and a new vial of insulin must be ordered immediately, and that medication administration staff are not to administer expired insulin. 2. At approximately 9:31AM during on-site inspection, one licensing inspector (LI) and staff 1 noted that the Lantus insulin pen in medication cart B for resident 9 was opened and had been used; however, the pen did not contain an open date. The manufacturer?s instructions for Lantus indicate that Lantus expires 28 days after the pen is opened.
Plan of Correction:	Lantus Pen was disposed of.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and staff interview, the facility failed to ensure medications were administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing (VBON). EVIDENCE: 1. The record for resident 4 contains a physician?s order, dated 01/31/2023, for Humalog insulin three times a day before meals with the following sliding scale instructions based on the resident?s blood sugar reading: 0-140 = 0 units; 141-170 = 1 unit; 171-200 = 3 units; 201-250 = 5 units; 251-300 = 7 units; 301-350 = 8 units; 351-400 = 9 units; greater than 400 = 10 units. 2. The April 2023 medication administration record (MAR) for resident 4 contains documentation that the resident?s blood sugar was 162 at 4:30PM which means that the resident should have received 1 unit of Humalog; however, the MAR indicates that the resident received 0 units of Humalog. 3. The current 68-hour registered medication aide curriculum, revised in 2022, indicates on page 50 that when an individual refuses medications that registered medication aides (RMAs) are to notify the health care provider regarding the refusal(s), observe and report effects of medication refusal(s), and document refusal(s) per the facility?s protocol. 4. The April and May 2023 MARs for resident 4 contain multiple instances during both months that the resident refused her prescribed Humalog insulin and Fluocinolone 0.01% solution. 5. During on-site inspection on 05/17/2023, the record for resident 4 did not contain documentation from any of the RMAs that had documented that the resident had refused these medications had notified the resident?s health care provider or observed and reported any effects of the medication refusals. 6. The record for resident 3 has documentation of a physician order for Humalog Insulin 10 units 3 times a day with meals plus sliding scale coverage. The May 2023 MAR for resident 3 has staff initials that are circled as not administering the Humalog Insulin on 05/01/2023 at 5:00pm. The MAR has documentation that the residents blood sugar was 81 and that ?physically unable to take?. The physician order does not have parameters to hold the Humalog Insulin for resident 3 and there is no documentation that resident 3?s physician was made aware of the blood sugar result or gave instructions to hold the medication.
Plan of Correction:	A training will be held to refresh med techs on the administration of insulin, proper documentation, and how to notify the doctor of each medication refusal.
Standard #:	22VAC40-73-860-I
Description:	Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area. EVIDENCE: 1. A can of Spar San Disinfectant Deodorant Spray was sitting out on the sink in the unlocked employee bathroom across from the nurses station. 2. A container of Clorox Disinfecting Wipes and a can of Claire Disinfectant Spray Q was sitting out on a table in the activity/puzzle room.
Plan of Correction:	Cleaning chemicals have been removed and staff have been instructed no to leave the chemicals out.
Standard #:	22VAC40-73-870-A
Description:	Based on observations of the facility physical plant, the facility failed to maintain the interior of the build and keep clean. EVIDENCE: 1. The carpet in the activity/puzzle room was noted to have numerous stains throughout the room on the day of inspection.
Plan of Correction:	Housekeeping cleaned the carpet and removed the stains.
Standard #:	22VAC40-73-950-E
Description:	Based on review of facility documentation, the facility failed to ensure that a six month review of emergency preparedness was conducted and signed by all residents. EVIDENCE: 1. A resident council meeting notes has documentation that fire and emergency preparedness were reviewed on 02/22/2023. The document has 16 resident names typed on the form as attending but no resident signatures were noted on the form. As of the day of inspection the facility currently has a census of 57 residents.
Plan of Correction:	Staff will conduct another meeting and then collect individual signature of all resident on 5/31/23.
Standard #:	22VAC40-73-990-C
Description:	Based on a review of facility documentation, the facility failed to ensure that a practice that included all components of resident emergency procedures was conducted with all staff currently on duty on each shift. EVIDENCE: 1. The facility practice of resident emergencies completed in January 2023 did not include all all components of their resident emergency procedures as required.
Plan of Correction:	Resident Emergency meetings will practice all components and document the scenarios of all future trainings.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to ensure criminal history record reports were obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. Staff 7 was hired at the facility on 08/15/2022; however, the Virginia Criminal History Record/Sex Offender and Crimes Against Minors Registry Search Form was not stamped as received by the Virginia State Police until 12/13/2022 indicating that the facility did not obtain the results a criminal history record report for staff 7 on or prior to the 30th day of the staff person?s employment.
Plan of Correction:	HR has been instructed on the proper timeline and required documentation for criminal history results.