VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Auburn Hill at Swift Creek
5800 Harbour Lane
Midlothian, VA 23112
(804) 250-5740

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date:

Complaint Related: No

Violations:

Standard #:	22VAC40-73-440-B
Description:	Based on record review, the facility failed to ensure an assisted living facility staff person who has completed the uniform assessment instrument (UAI) has it signed by the administrator or the administrator's who approves and then signs the completed UAI. Evidence: Resident #9?s UAI dated 10-07-2022 and Resident #10?s UAI dated 9-29-2022 were only signed by former director of memory care, and not by the administrator or designee as having approved the UAIs.
Plan of Correction:	Facility will ensure that the staff person completing the UAI (uniform assessment instrument) will sign and date it and will make sure that the administrator or administrator?s designee also signs and dates for approval of the completed UAI.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview with staff, the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs and date identified based upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources. Evidence: 1.Resident #2 admitted 6-21-2023. Resident #2?s Uniform Assessment Instrument (UAI) dated 8-08-2023 documented wheeling and stairclimbing assistance as ?human help, physical assistance? and that resident is disoriented; however, those needs were not identified on the comprehensive ISP dated 8-08-2023. The resident resided in the special care unit (SCU) which was not on the resident?s ISP. 2.Resident #7 admitted 4-28-2023. Resident #7?s UAI dated 6-22-2023 documented transferring assistance as ?mechanical help, human help physical assistance? and that resident is disoriented; however, those needs were not identified on the comprehensive ISP dated 8-03-2023. The resident resided in the SCU, which was also not on the resident?s ISP. 3.Resident #8 admitted 5-16-2023. Resident #8?s UAI dated 6-16-2023 documented behaviors as ?wandering?; however, the ISP dated 6-16-2023 did not identify this service need.
Plan of Correction:	Facility will ensure that the comprehensive individualized service plan (ISP) shall include description of identified needs and date identified based upon the UAI (uniform assessment Instrument), admission physical examination, interview with resident, fall risk rating and if appropriate assessment of psychological, behavioral, and emotional functioning and other sources. This will be the responsibility of our Memory Care Director and/or our Director of Health and Wellness. Resident # 2- Deceased on 08/21/2023 Resident # 7- Deceased on 9/14/2023 Resident #8- ISP updated on 11/01/2023 An audit of all resident UAIs and ISPs will be conducted to ensure all needs assessed on the UAI are captured on the ISP. Director of Health and Wellness will provide all individuals completing UAIs a copy of the UAI manual. ED will ensure prior to all resident signatures that all assessed needs on the UAI are captured in the ISP.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to ensure individualized service plans (ISPs) were updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. Resident #10 admitted 2-15-2022. Resident #10?s UAI dated 9-29-2022 documented the resident has wandering behaviors; however, the most recent ISP 9-2022 did not identify wandering behavior. The resident also resided in the Special Care Unit (SCU); however, it was not addressed on the ISP. 2.Resident #9 admitted 2-15-2021. Resident #9?s UAI dated 10-2022 identified the resident as bowel and bladder incontinent, weekly or more; however, the ISP dated 8-22-2023 documented the resident as ?continent?. Additionally, the resident?s UAI documented the resident has wandering behaviors and is disoriented, which neither were addressed on the ISP. 3.Resident #6 admitted 2-25-2022. Resident #6?s UAI dated 10-04-2022 documented the resident has bowel incontinence; however, the ISP dated 8-25-2023 documented ?continent?. 4.Resident #1 admitted 2-01-2022. Resident #1?s UAI dated 3-29-2023 documented the resident requires ?mechanical help, human help physical assistance? with bathing, and ?mechanical help, human help supervision? with transferring; however, neither need was addressed on the ISP dated 3-28-2023.
Plan of Correction:	Facility will ensure that ISP?s (Individual service plan) will be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. This will be the responsibility of our Memory Care Director and/or our Director of Health and Wellness. Resident #10- updated on 11/01/2023 for Assessment and care plan to match Resident # 9- updated on 11/01/2023 for UAI to match ISP Resident #6- updated on 11/01/2023- for UAI to match ISP Resident #1- updated on 11/01/2023 for UAI to match ISP
Standard #:	22VAC40-73-970-E
Description:	Based on record review, the facility failed to ensure a record of the required fire and emergency evacuation drills included the number of residents participating. Evidence: The 5-29-2023 Fire and Emergency Evacuation Drill at 10:30 p.m. was blank under ?Number of residents participating:?.
Plan of Correction:	Facility will ensure that a record of the required fire and emergency evacuation drills include the number of residents participating. This will be the responsibility of our Director of Environmental Services or the Director of Environmental Services assistant/designee.