VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Golden Years Assisted Living Facility, Inc.
40 Hunt Club Boulevard
Hampton, VA 23666
(757) 825-2425

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: March 13, 2023 and May 10, 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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

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: 3/13/2023 7:54 am- 5:05 pm and 5/10/2023 3:00 pm- 4:00 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: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 5 Number of interviews conducted with residents:4 Number of interviews conducted with staff: 5 Observations by licensing inspector: 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 Alyshia E. Walker, Licensing Inspector at (757)670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on resident record review and interviews with staff, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of one resident. Evidence: 1. During on-site inspection and record review of Resident #8?s record, an incident report was in the file which documented that the resident was found on the floor in front of his wheelchair with a laceration on the back of his head. Hospice was contacted. The facility did not notify the local licensing office of the incident. 2. The facility was placed on Fire Watch by the local Fire Marshall on 6/28/22. The local licensing office was not notified of the incident.
Plan of Correction:	1. Admin will contact the licensing office of all injuries that require hospital visit. 2. Admin will contact licensing office if we have to be on Fire Watch, we will report the date and possible duration and reason for that event.
Standard #:	22VAC40-73-210-F
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure at least two of the required hours of training focused on infection control. When adults with mental impairment reside in the facility, at least four of the required hours shall focus on topics related to residents? mental impairment for three staff members. Evidence: 1. Record review for staff # 1, (date of hire 2/10/17), #10 (date of hire 4/1/21) and #9 (date of hire 6/18/21) did not include documentation of the required two (2) hours of infection control and four (4) hours of mental impairment training. 2. Staff #1 and #2 acknowledged the staff members records did not include the required training hours.
Plan of Correction:	1. Administration has scheduled several required in-services for staff including infection control. In-services will be conducted on site by Home Health Agency.
Standard #:	22VAC40-73-250-D
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a subsequent tuberculosis (TB) evaluations and reports was in the record for two staff members. Evidence: 1. On 3/13/23, staff #1 TB results in the record was dated, 1/29/21 and 12/21/21, staff?s date of hire noted as 2/10/17. 2. Staff #8?s record did not include a current TB, staff?s date of hire noted as 4/13/22.
Plan of Correction:	Administrator or designee will request new hired staff to present TB report before starting the new hire documents.
Standard #:	22VAC40-73-310-B
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure a documented interview between the administrator or designee responsible for admission and retention, the individual, and the legal representative, if any was in the record for a resident. Evidence: 1. Resident #6?s record did not include documentation of an interview. The resident?s date of admission noted as 4/16/23.
Plan of Correction:	Administrator or designee will document "interview" on initial assessment of new and potential residents.
Standard #:	22VAC40-73-310-H
Description:	Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without a treatment plan. Evidence: Resident #6?s March MAR documented the resident was prescribed Zoloft. The resident?s file did not contain a psychotropic treatment plan for the medication.
Plan of Correction:	Treatment plans will be added to ISP to address psychotropic medications.
Standard #:	22VAC40-73-320-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a risk assessment was completed annually for a resident as evidence by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it for a resident. Evidence: On 3/13/23, resident #8?s, record did not include a current risk assessment for tuberculosis (TB). The assessment in the record was dated 8/31/21.
Plan of Correction:	Risk assessments for TB will be reviewed every 6 months and updated annually.
Standard #:	22VAC40-73-320-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a risk assessment was completed annually for a resident as evidence by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it for a resident. Evidence: On 3/13/23, resident #8?s, record did not include a current risk assessment for tuberculosis (TB). The assessment in the record was dated 8/31/21.
Plan of Correction:	Risk assessments for TB will be reviewed every 6 months and updated annually.
Standard #:	22VAC40-73-410-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the record included an acknowledgement of having received the orientation and shall be signed and dated by the resident, and as appropriate the legal representative and shall be kept in the resident?s record. Evidence: On 3/13/23, resident #6?s record did not include documentation of an orientation for new residents which included information regarding mealtimes, the use of the call system, and the emergency response procedures.
Plan of Correction:	Upon completion of admission, the orientation document will be signed and dated by resident or legal representative and filed in resident record. All resident records will be reviewed annually to assure all documents are current and signed.
Standard #:	22VAC40-73-410-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the record included an acknowledgement of having received the orientation and shall be signed and dated by the resident, and as appropriate the legal representative and shall be kept in the resident?s record. Evidence: On 3/13/23, resident #6?s record did not include documentation of an orientation for new residents which included information regarding mealtimes, the use of the call system, and the emergency response procedures.
Plan of Correction:	Upon completion of admission, the orientation document will be sign and dated by resident or legal representative and filed in resident record. All residents records will be reviewed annually to assure all documents are current and signed.
Standard #:	22VAC40-73-440-K
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it was in compliance with the requirements set forth in 22VAC30-110. Evidence: On 3/13/23, Resident #8?s uniformed assessment instrument (UAI) dated 10/11/22 was completed by a facility staff. The document was not signed by the administrator or designee.
Plan of Correction:	Administrator or designee will sign all UAI's upon completion of review.
Standard #:	22VAC40-73-450-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the resident or the legal representative. Evidence: On 3/13/23, resident #8?s ISP dated 11/10/22 was not signed by the resident or a legal representative.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the resident or the legal representative. Evidence: 1. On 3/13/23, resident #7?s ISP in the record had and end date/review date of 7/20/22. The 11/1/18. 2. Resident #8?s record included a comprehensive hospice assessment dated 10/11/22 and document from a medical clinic dated 12/15/21 documenting resident?s allergy to Ativan and Aricept. The resident?s medication administration record (MAR) for March 2023 documented resident prescribed Lorazepam (Ativan). The record included an order from hospice to discontinue Ativan in November 2022. The resident?s ISP dated 11/10/22 did not include documentation of the resident?s allergy to Aricept and Lorazepam (Ativan).
Plan of Correction:	1. Administrator and designee will sign all ISP's upon completion of review. 2. Facility will notify pharmacy of known allergies and it will be indicated on ISP and UAI by Admin or designee.
Standard #:	22VAC40-73-680-B
Description:	Based on observation and staff interview, the facility failed to ensure medication shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. Evidence: On 3/13/2023, during an on-site observation of the medication pass with Staff #10, the licensing inspection observed repoured medications for 17 residents in the top drawer of 2 medication carts.
Plan of Correction:	Admin and RMA's will ensure that no medication will be repoured. All medications will be poured at the time of administering.
Standard #:	22VAC40-73-860-G
Description:	Based on observations and staff interviewed, the facility failed to ensure the hot water at taps available to residents was maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F. Evidence: 1. On 3-13-23, during a tour of the facility with staff #5, the water temperature in bathroom for room #21 was 150 degrees F. The temperatures in room #37 and #38 were observed with a temperature of 130 degrees F. 2. Staff # 5 and # 3 acknowledged the hot water temperatures were not maintained within a range of 105- 120 degrees F.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-E
Description:	Based on observation and staff interviewed, the facility failed to ensure all furnishings, fixtures, and equipment was in good repair. Evidence: On 3/13/23, during a tour of the facility with staff #5, the facility?s signaling system/call bell was not working. The call bell in room #11 and #12 was pulled but there was no response and did not light up outside the door. Staff #5 went to the nursing station where the calls terminate. Once in the room, staff discovered the system was turned off. Once the system was turned back on, the call bells for several rooms could be observed with the light on outside the room doors and the sound of call bells ringing could be heard throughout the building
Plan of Correction:	The call bell system is working. It has been tested from several rooms and light signals comes on in the hallway. A lock has been put on the call bell system box to assure that it does not get switched off. The system is operating as it should.
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the first aid kit for the building included all required items. Evidence: On 3/13/23, a check of the facility?s first aid kit was conducted with staff #2. The kit did not include roller gauze of any sizes. The kit also did not include antiseptic wipes or ointment.
Plan of Correction:	The first aid kit has been inventoried and restocked with supplies that are required and the check list has been updated.