VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Babcock Manor, Inc.
State Route 691
Appomattox, VA 24522
(434) 352-8686

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

Inspection Date: June 26, 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: 06/26/2023 9:30am until 2:30pm 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: 27 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: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 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 #:	22VAC40-73-200-C
Description:	Based on review of staff records, the facility failed to ensure that the direct care staff met the required training requirements EVIDENCE: 1. The record for staff person 5, hired on 04/10/2023, did not contain documentation that this employee has direct care certification/training. An interview was conducted with staff person 6 who expressed that this employee, who works the 3rd shift as a care aid, has not completed direct care staff training.
Plan of Correction:	The administrator will have this individual enroll and complete a direct care training program.
Standard #:	22VAC40-73-250-D
Description:	Based on review of staff records, the facility failed to ensure a screening for tuberculosis was completed on or within seven days prior to the first day of work for new employees. EVIDENCE: 1. The record for staff person 5, hired on 04/10/2023, has documentation that a screening for tuberculosis was not completed until 06/02/2023.
Plan of Correction:	The administrator will ensure that new employees have a screening for tuberculosis prior to the first day of work.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, an individualized service plan (ISP) was not completed as required. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 2, dated 12/17/2022, indicates that the resident is disoriented some spheres, some of the time to date and day; however, the ISP for resident 2, dated 12/17/2022, does not indicate the aforementioned information. Interview with staff 2 confirmed that the UAI is correct and this information needs to be included on the resident?s ISP. 2. The UAI dated 05/02/2023 in the record for resident 6 has documentation that the resident is disoriented to some spheres some of the time with time being the sphere affected. The ISP dated 05/02/2023 in the record for resident 6 does not address this identified need.
Plan of Correction:	The administrator will update ISPs to reflect identified needs.
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?s for resident 1, dated 07/19/2022, resident 2, dated 12/17/2022, resident 3, dated 02/10/2023 and the ISP for resident 5, dated 04/01/2023, were not signed and dated by the resident or his legal representative.
Plan of Correction:	The administrator will have residents/families sign ISPs.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of resident and staff records, the facility failed to ensure that am annual review of resident rights was completed with residents and staff. EVIDENCE: 1. The records for residents 2, 3, 5 and 6 and the records for staff 2 and 3 did not contain documentation that these individuals received an annual review of residents rights.
Plan of Correction:	The administrator will ensure that an annual review of resident rights is completed with all residents and all staff.
Standard #:	22VAC40-73-610-D
Description:	Based on resident record review and staff interview, the facility failed to ensure that when a diet is prescribed for a resident by his physician or other prescriber, that it is prepared and served according to the physician?s or other prescriber?s orders. EVIDENCE: 1. The record for resident 2 contains a signed order, dated 12/28/2022, for the resident to be on a fluid restriction of 64 ounces daily. Interview with staff 2 revealed that staff are not ensuring that the resident only receives 64 ounces of fluid daily. Interview with staff 3 revealed that she was not aware of the order for the resident to only receive 64 ounces of fluid daily. 2. The most recent dietitian oversight was dated 04/06/2023 and lists 13 residents with a special diet. A list of special diets was not observed in the kitchen on the day of inspection. Interview with staff person 3 expressed that everyone receives the same meals and was not aware of special diet orders for any resident.
Plan of Correction:	The administrator had the fluid restriction diet for resident 2 discontinued as the resident is on hospice. The administrator will review all current special diets and ensure that an updated posting is in the kitchen. The administrator will in-service all dietary and direct care staff on the importance of preparing and serving special diets.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to ensure that medications are administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 2 contains a signed order, dated 12/28/2022, to hold the resident?s prescribed Carvedilol 3.125 MG when the resident?s systolic blood pressure is less than 110. The 05/21/2023 through 06/20/2023 medication administration record (MAR) for resident 2 contains documentation that the resident?s blood pressure was 108/65 on 06/08/2023; however, the MAR contains documentation that Carvedilol 3.125MG was administered to the resident when it should have been held.
Plan of Correction:	The administrator will have an in-service for all medications aids on proper documentation and following physician orders.
Standard #:	22VAC40-73-680-E
Description:	Based on resident record review and staff interview, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber were provided according to his instructions and documented and the documentation is to be maintained in the resident?s record. EVIDENCE: 1. The record for resident 2 contains a signed order, dated 12/28/2022, to hold the resident?s prescribed Carvedilol 3.125 MG when the resident?s systolic blood pressure is less than 110. Interview with staff 2 revealed that staff document the resident?s blood pressure on the back of the medication administration record (MAR). The 05/21/2023 through 06/20/2023 MAR for resident 2 indicates that the resident was administered Carvedilol 3.125 MG at 7:00AM on 05/28/2023 and 06/20/2023; however, the MAR did not include documentation of what the resident?s blood pressure was. Interview with staff 2 confirmed that this was accurate and could not locate the blood pressure readings for the resident at 7:00AM on 05/28/2023 and 06/20/2023 during the on-site inspection. 2. The record for resident 5 contains the following orders for oxygen: Use two liters of oxygen, dated 01/06/2023, at all times to keep oxygen status greater than 89%; keep using oxygen as much as needed, dated 04/17/2023, oxygen goal for the resident is 89% - 93%; and hospital discharge instructions signed by a physician, dated 06/12/2023, continuous oxygen at three liters via nasal cannula. During on-site inspection on 06/26/2023, one licensing inspector (LI) spoke with staff 2 regarding documentation by staff to ensure that the resident is using oxygen continuously. Staff 2 stated that staff are not documenting resident 5?s oxygen usage.
Plan of Correction:	The administrator will have an in-service for all medications aids on proper documentation and following physician orders.
Standard #:	22VAC40-73-710-C
Description:	Based on observations and resident record review, the facility failed to ensure that a restraint was only used in accordance with physician orders/instructions. EVIDENCE: 1. During a tour of the facility physical plant, both LI?s in the presence of staff person 1 observed resident 3 lying in bed with half rails up on both sides. The back of a recliner chair was placed at the side of the bed from the end of the half rail towards the foot of the bed and a wheelchair was placed at the side of the bed towards the end of the bed. Interview with staff person 1 expressed that this is done to keep resident 6 from trying to climb out of the bed. A review of the record for resident 6 noted that there is not a physician order for a restraint to keep resident 6 from climbing out of bed.
Plan of Correction:	The administrator has in-serviced all direct care staff on the proper use of recliner chairs and wheelchairs. The administrator will consult with the resident?s physician on the residents needs for half rails and bed mats and will obtain proper physician orders.
Standard #:	22VAC40-73-870-A
Description:	Based on observation during a tour of the physical plant, the facility failed to ensure that the interior of the building is maintained in good repair. EVIDENCE: 1. The baseboard heater across from room 2 was noted to be separating from the wall. 2. The floor in the hallway next to the dining room was noted to have several cracks/gaps between the floor boards. 3. The public restroom upstairs by the nursing office was noted to have an inoperable door knob on the day of inspection as the door would not stay closed. 4. The door frame around the door to room 10 was noted to be broken/cracked on the day of inspection.
Plan of Correction:	The administrator has talked with maintenance and will have physical plant repairs completed.
Standard #:	22VAC40-90-40-B
Description:	Based on review of staff records, the facility failed to ensure that a completed criminal history report was received within the first 30 days of employment. EVIDENCE: 1. The record for staff person 5, hired on 04/10/2023 did not contain documentation of a completed criminal history report on the day of inspection.
Plan of Correction:	The administrator will ensure that all new staff have a completed criminal history report within 30 days of the day of employment. Employee 5?s criminal report has been requested and the administrator is awaiting the results.