VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Elance at Tuckahoe
567 N. Parham Road
Henrico, VA 23229
(804) 554-3939

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Nov. 6, 2023

Complaint Related: No

Comments:

Number of residents present at the facility at the beginning of the inspection: 77 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: Yes

Violations:

Standard #:	22VAC40-73-450-A
Description:	Based on the review of facility records and interviews conducted with facility staff the facility failed to develop on or within seven days prior to the day of admission, a preliminary plan of care to address the needs of the resident that adequately protects his health, safety, and welfare. Evidence: Resident #3: Documented date of admission 11/20/2023 The resident?s 10/28/2023 Individualized service plan (ISP) that was reviewed with the facility Administrator revealed the following: The facility notes that the resident is independent in the administration of his own medications. For clarification the Administrator stated during interviews that residents are reassessed every 6 months or if there is a change in condition when determining whether the resident can continue to be independent in medication administration. The resident?s 10/28/2023 ISP does not identify the need for a reassessment to determine if the resident is still capable of self-administering medications. The facility did not identify on the resident?s 10/28/2023 ISP the specific services that will be provided to the resident from the home health agency regarding the foley/catheter care and PT/OT.
Plan of Correction:	FACILITY'S RESPONSE: "Immediate: Identified resident?s ISP will be modified to reflect six month reassessment for ability to continue to manage his own medications, and Detailed catheter care was added. Audit: The Director of Health and Wellness will audit the files of all residents who self administer their medications to ensure that they reflect the six month reassessment for ability to continue to manage his own medications. Systemic: Nursing team was reeducated to the need for relecting the ongoing monitoring of ability to pass meds in the ISP Monitoring: Executive Director will review all ISPs for accuracy upon completion or updating."
Standard #:	22VAC40-73-450-F
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that Individualized service plans were updated as needed for a significant change of a resident?s condition. Evidence: Resident #2: Documented date of admission 02/18/2023 The residents? 11/02/2023 Physician Order Review document and the residents? medication administration records charting for November 2023 that was reviewed with the facility Administrator notes ?Mechanical soft diet and ?Every eight hours. Every day at 7:30a.m, 3: 30p.m, 11:00p.m. Supervise all PO?. For clarification after reviewing the residents? 11/02/2023 MAR the facility Administrator stated that facility staff are to note on the resident?s MAR every eight hours 7:30a.m, 3: 30p.m and 11: 30p.m, whether the resident is pocketing any oral intake. The residents? MAR charting for November 2023 that was reviewed by the inspector on 11/02/2023 and with the facility Administrator on 11/06/2023 revealed that facility staff did not document on 11/01/2023 at 3:30p.m whether the resident was pocketing any oral intake. The resident?s 10/04/2023 ISP that was reviewed with the facility Administrator is not documented to identify the need for facility staff to document whether the resident is pocketing oral intake.
Plan of Correction:	FACILITY'S RESPONSE: "Immediate: Identified ISPs were updated Audit: Director of Health and Wellness and Director of Virtue will review and countersign one another?s ISPs. Systemic: Director of Virtue and Director of Health and Wellness will audit all ISPs for accuracy. Monitoring: Executive Director will review five ISPs a week for accuracy. Director of Health and Wellness, Director of Virtue, Executive Director "
Standard #:	22VAC40-73-560-F
Description:	Based on observation and interviews conducted the facility failed to ensure that all resident records are treated confidentially. Evidence: While onsite at the facility on 11/06/2023 accompanied by the Administrator, the facility?s Staff Communication Book on the 2nd floor was observed unattended and being stored on top of the medication cart. Upon further review of the book with the Administrator it was revealed that personal information regarding resident admissions, medication administration, the whereabouts of residents and resident ambulatory status. The facility did not ensure that resident records were treated confidentially.
Plan of Correction:	FACILITY'S RESPONSE: "Immediate: The 24 hour communication log was removed from the top of the medication cart. Audit: Staff will confirm during change of shift that all items with confidential information are put away. Systemic: Staff will be reeducated on the importance of putting away all items with confidential information. Monitoring: Daily walkthrough will be increased to two times per day by Manager on Duty and Executive Director Executive Director/Manager on Duty"
Standard #:	22VAC40-73-640-A
Description:	Based on the review of facility records and staff interviews conducted the facility failed to ensure that methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order were implemented. Evidence: Resident #4: Documented date of admission 09/15/2023 The facility records for the resident that was reviewed with the facility Administrator revealed the following: The residents? 09/13/2023 physician?s orders noting to take 5mg Dronabinol two times a day until 09/30/2023 and indicating the quantity to be 30. The facility?s Controlled Drug Record document dated 09/14/2023 notes the quantity of the medication Dronabinol as 10. In regard to the 5mg of the medication Dronabinol a facility?s 09/14/2023 Communication Form document from the facility?s identified pharmacy noted ?Medication is not covered under the resident?s insurance policy. PA Needed?. The resident?s MAR charting for 09/15/2023 notes that the resident was administered the medication at 5p.m. The facility?s Controlled Drug Record document does not identify that the resident was administered the medication on 09/15/2023 at 5p.m. Facility staff documented that the medication was administered on 09/17/2023 at 8a.m but the controlled substance record is not documented to note that the medication was administered. Facility staff did not implement a plan to monitor the resident?s September 2023 MAR to ensure that physician?s orders have been accurately transcribed.
Plan of Correction:	FACILITY'S RESPONSE: "Immediate: The order referenced was verified. Audit: After the LPN charge nurse verifies new orders she will confirm that the pharmacy has sent the medication with the new order accurately reflected on both the new order and the narcotic count sheet. Systemic: The DHW verifies behind the charge nurse that new orders are transcribed correctly and that new medication cards are ordered to reflect changes as well as new narcotic sheets implemented for new order. Monitoring: Executive Director will audit three random orders a week to determine that the cards match the orders."