VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Auburn Hill at Swift Creek
5800 Harbour Lane
Midlothian, VA 23112
(804) 456-4455

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: March 30, 2023

Complaint Related: Yes

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: March 30, 2023; 12:20 ? 1:40 p.m. 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 March 18, 2023 regarding allegations in the area of: Buildings and Grounds, Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violation(s) were 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on record review, the facility failed to ensure the uniform assessment instrument (UAI) was completed whenever there was a significant change in the resident's condition. Evidence: Resident #2 admitted 9-18-2020. Resident #2?s current UAI dated 8-24-2022 did not document ?wheeling? as a service need; however, the resident?s current ISP (undated) documented, ?[Resident #2] uses [Resident #2]?s wheelchair and cane when ambulating/transferring.? Additionally, Resident #2 was observed by the licensing inspector utilizing a motorized wheelchair on 3-30-2023 and was documented to use a wheelchair since admission.
Plan of Correction:	DHW and Designee will ensure that UAI is updated in a timely manner whenever there is a significant change in a resident?s condition. Resident changes in condition will be reviewed during stand-up meetings which are typically held at least 4 days a week. Resident #2 Residents is discharged and no longer reside in the community.
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on record review, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative. These requirements shall also apply to reviews and updates of the plan. Evidence: The following residents? ISPs were not signed or dated by licensee, administrator, or his designee, and by the resident or his legal representative: a. Resident #1 (admitted 11-04-2020), b. Resident #2 (admitted 9-18-2020), and c. Resident #4 (admitted 12-21-2022).
Plan of Correction:	Resident # 1 and Resident #2 The resident no longer reside in the community. Resident #4 is currently out of the community and will be reassessed upon return. Education will provide education for all directors on how to manage and respond to resident council concerns in a timely manner. resident or his legal representative.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on record review, the facility failed to ensure that individualized service plans (ISPs) were reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. Resident #2 admitted 9-18-2020. Resident #2?s current ISP that was undated documented the resident requires physical assistance with bathing; however, the UAI dated 8-24-2022 documented the resident requires mechanical and physical assistance with bathing. Additionally, Resident #2?s ISP did not document the resident?s allergies or allergy reactions for the resident?s reported allergies to Septra, Tetracycline, and Enalopril documented on the personal and social data sheet. 2. Resident #3 admitted 8-19-2022. Resident #3?s current ISP dated 8-26-2022 did not document the resident?s allergies or allergic reactions for the resident?s reported allergies to Aspirin and Tramadol documented on the personal and social data sheet.
Plan of Correction:	DHW or designee will ensure the uniform assessment instrument (UAI) will be updated and completed in a timely manner. Resident #2 Resident is discharged and no longer reside in the community. Resident #3?s ISP was updated to include allergies. DHW or designee will conduct audits for all current residents to ensure that allergies are addressed in the service plan. Will be provided to all team members who complete UAI?s and ISP?s regarding assessed needs being part of the ISP.
Standard #:	22VAC40-73-830-E
Complaint related:	No
Description:	Based on record review, the facility failed to provide a written response to the council prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns. Evidence: Resident Council Notes on the following dates with the following concerns did not have a written response with resolution of problems or concerns: A. 01-24-2023: Eight dining concerns, one housekeeping/laundry concern, two direct care staff concerns, and three maintenance concerns; B. 02-22-2023: Eight dining concerns, two housekeeping concerns, two direct care staff concerns, and one maintenance concern. C. 03-29-2023: Three dining concerns, one direct care staff concern, and two maintenance concerns.
Plan of Correction:	ED or designee will provide education for all directors on how to handle and respond to resident council concerns in a timely manner.
Standard #:	22VAC40-73-870-I
Complaint related:	Yes
Description:	Based on interview with staff and record review, the facility failed to ensure that elevators were kept in good running condition. Evidence: 1. An email with a service call regarding the facility?s elevator dated 3-17-2023 documented that the elevator was not working properly at the facility and documented, ?Stuck on jack resync. Reset and forced resync. Operating normally now??. 2. Subsequently, the elevators had been out of service on 11-23-2022, 1-07-2023, and 2-18-2023 per service logs reviewed. 3. Staff #1 confirmed the elevator at the facility was not kept in good running condition on the four documented dates.
Plan of Correction:	The elevator has been serviced and is currently in good working condition. ED and/or Designee will continue to ensure that the elevator remains in good working condition. Elevator inspection is schedule for March 2024 and is conducted annually. ED will ensure that any recommendation made at the time of inspection will be followed up on promptly.