VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Assisted Living at Lucy Corr
6800 Lucy Corr Boulevard
Chesterfield, VA 23832
(804) 748-1511

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: Feb. 15, 2024

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

Comments:

Type of inspection: Renewal Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 2/15/24, 10 a to 1 p The Acknowledgement of Inspection form was emailed for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 45 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: 4 Number of interviews conducted with residents: Number of interviews conducted with staff: 3 Observations by licensing inspector: Medication storage and administration, resident/staff interactions, lunch meal, building cleanliness and maintenance, required postings. 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 Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-630-A
Description:	Based on an observation of medication administration, medication ordered for PRN administration was not available for one resident. Evidence: The Medication Administration Record (MAR) for resident # 7 has an order for Tylenol 325mg PRN. The medication was not found in the medication storage cart. Staff reported that the medication needed to be refilled and was not available.
Plan of Correction:	LPN?s and RMA?s will be in-serviced to re-order meds when they are down to one week?s worth of remaining meds. This will be completed by 2/26/2024 to include all shifts.
Standard #:	22VAC40-73-720-A
Description:	Based on a review of file documentation, the written Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident were not included on the individualized service plan. Evidence: Resident # 1 has DNR Orders dated 4-25-23 that were not included on the resident individualized service plan.
Plan of Correction:	ISP will be updated. All ISP?s belonging to residents with DNR?s will be checked to ensure accuracy, This has been completed on 2/19/2024.
Standard #:	22VAC40-73-930-D
Description:	Based on file reviews, for each resident with an inability to use the signaling device, the inability was not included in the resident`s individualized service plan for three residents. Evidence: Residents # 1, # 2 and # 3 reside in the safe, secure environment due to a serious cognitive impairment with an inability to recognize danger or protect his own safety and welfare. The individualized service plans for the residents did not address their ability/inability to use the signaling device.
Plan of Correction:	All residents admitted to the safe, secure environment will have ?inability to use signaling device? updated on ISPs. This has been completed on 2/19/2024