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

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS

Technical Assistance:

ISP Signatures

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: 3/30/2023, 1:41 ? 2:30 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 9, 2023 regarding allegations in the area of: Admission, Retention, and Discharge of Residents; 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 some, but not all of the allegations; area of non-compliance with standard(s) or law was: Admission, Retention, and Discharge of Residents. 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 Alexandra Poulter, Licensing Inspector at 804-662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-A
Complaint related:	No
Description:	Based on record review, the facility failed to ensure the physical examination for the person contained a description of the person?s reaction to any known allergies. Evidence: Resident #2 admitted 12-09-2021. Resident #2?s ?Report of Resident Physical Examination? dated 12-09-2021 documented allergies to Timoptic, Lisinopril, Toprol, and Fresh oranges/orange juice; however, no allergy reactions were documented.
Plan of Correction:	Resident#2: Resident has been discharged, no longer resides in community. ED/DHW or designee will review H&P documentation for all new admissions to ensure documentation of allergy/allergic reactions is completed.
Standard #:	22VAC40-73-325-B
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure the fall risk rating was reviewed and updated after a fall. Evidence: 1. Resident #1 had an unwitnessed fall approximately a few days before 7-12-2022 per physician?s ?Progress Note? dated 7-12-2022; however, no fall risk rating was completed for this incident. 2.Resident #2 had a fall on 10-15-2022 per a telephone order to the resident?s PCP [primary care provider] dated 10-15-2022; however, no fall risk rating was completed for this incident. 3.Resident #3 had falls on 1-01-2023, 1-06-2023, and 3-08-2023 per the resident?s ?Progress Notes?; however, there were no fall risk ratings completed for the three dated incidents.
Plan of Correction:	Resident #1: Resident has been discharged since this incident and no longer resides in community. Education to H&W team members who complete Morse Fall scale on Fall Response Policy and Fall Reduction Program. ED/DHW or designee will monitor for completion of Morse Fall Scale post resident fall during stand-up meetings which are typically held 4 times per week. Resident #2: Resident was discharged and no longer resides in the community. Resident #3: Resident was discharged and no longer resides in community. .
Standard #:	22VAC40-73-325-C
Complaint related:	No
Description:	Based on record review and interview, the facility failed to show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls. Evidence: 1. The following three residents? records did not contain documentation of an analysis of the circumstances of the falls, and interventions that were initiated to prevent or reduce risk of subsequent falls: a. Resident #1?s fall documented 7-12-2022 per the resident?s physician?s progress notes. b. Resident #2?s fall documented 10-15-2022 per a facility note to the resident?s physician. c. Resident #3?s falls documented 1-01-2023, 1-06-2023, and 3-08-2023 per the resident?s progress notes. 2. Additionally, the aforementioned residents? individualized service plan (ISP) did not identify interventions initiated to prevent or reduce risk of subsequent falls.
Plan of Correction:	Resident #1#,2#, #3: Residents have been discharged and no longer reside in the community. Education to H&W team members who participate in updating ISPs on Fall Response Policy and Fall Reduction Program. DHW/DIMC or designee will ensure ISPs are updated with appropriate interventions post resident fall.