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: Dec. 18, 2023 and Feb. 12, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/8/2023, 2/12/2024 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/21/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 16 Number of staff records reviewed:3 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. 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 Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-40-B
Complaint related:	No
Description:	Based on staff record review, the facility failed to obtain the criminal history record report on or prior to the 30th day of employment for two employees. Evidence: During the inspection conducted on December 8, 2023 and February 12, 2024, a record review indicated: 1. The date of hire for Staff #3 was 04/17/2023; the staff?s record did not contain a completed criminal history record report. 2. The date of hire for Staff #4 was 11/29/2023; the staff?s record did not contain a completed criminal history record report.
Plan of Correction:	1. Counseling and re-education were provided to the staff member responsible for the new hire process. 2. A new process has been established, whereas upon hiring a new employee, a copy of the criminal background request form will be attached to the new hire packet that is sent to the timekeeper. The timekeeper will upload the request form to the HR file and note that it has been completed. All new hire files will be submitted to the Assistant Director for review by the end of the business day. 3. We have requested access from the Virginia State Police to complete criminal background checks online, which will facilitate the tracking process and ensure they are completed in a timely manner.
Standard #:	22VAC40-73-60-B
Complaint related:	No
Description:	Based on record review, the facility failed to ensure its use of electronic records or signatures complied with the provision of the Uniform Electron Transaction Act. Evidence: 1. A review of the May 2023 electronic Medical Administration Record for Resident #14 documented Staff #6?s electronic signature was used on 5/18/23, 5/19/23, 5/22/23, 5/25/23, 5/26/23, and 5/29/23 to document medication was administered to the resident. 2. An email received from the facility to the Licensing Inspector verified Staff #6?s last day employed at the facility was 5/17/2023.
Plan of Correction:	1. Re-education on use of electronic signatures was provided to medication aides. 2. A process for a weekly review of the MAR is being established (i.e. nursing supervisor will audit the MAR on a weekly basis to identify errors and discrepancies and carry out counseling and/or disciplinary action as needed.
Standard #:	22VAC40-73-120-A
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted with facility staff failed to ensure that the orientation and required training occurred within the first seven working days of employment. Evidence: The orientation dates on the orientation sheet in the staff records for Staff #3 and #4 were blank and there was no signature that the orientation was conducted.
Plan of Correction:	1. Counseling and re-education were provided to the staff member responsible for the new hire process. 2. All new hire files will be submitted to the Assistant Director for review by the end of the business day.
Standard #:	22VAC40-73-150-B-2
Complaint related:	No
Description:	Based on interviews conducted, the facility failed to immediately notify the Virginia Board of Long-Term Care Administrators and or the regional licensing office that the licensed administrator resigned, was discharged, or became unable to perform his duties and that a new licensed administrator has been employed or that the facility is operating without an administrator licensed by the Virginia Board of Long-Term Administrators, whichever is the case, and provide the last date of employment of the previous licensed administrator. Evidence: 1. During the on-site inspection on 12/8/2023, Staff #1 notified the Licensing Inspector that her last day would be on 12/20/2023. 2. During the on-site inspection on 2/12/2024, the Licensing Inspector was informed by Staff # 5 the facility does not have an administrator and has not had an administrator since Staff #1?s departure.
Plan of Correction:	1. The facility will notify the Virginia Board of Long Term Care Administrators and the regional licensing office immediately of any changes in administrator. 2. We have hired an administrator, and her start date is 3/20/24. The licensing office will also be informed.
Standard #:	22VAC40-73-210-C
Complaint related:	No
Description:	Based on the on-site record review and staff interview the facility failed to ensure training for the first year shall commence no later than 60 days after employment. Evidence: The staff records for Staff # 3 and #4 contained training logs which were blank.
Plan of Correction:	1. Counseling and re-education were provided to the staff member responsible for the new hire process. 2. All new hire files will be submitted to the Assistant Director for review by the end of the business day.
Standard #:	22VAC40-73-260-C
Complaint related:	No
Description:	Based on record review and interview with staff, the facility failed to ensure each direct care staff member maintained current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. To be considered current, first aid certification from community colleges, hospitals, volunteer rescue squads, or fire departments shall have been issued within the past three years. Evidence: 1. The staff records for Staff members # 3 and #4 did not contain evidence of current First Aid certification. 2. Staff #5 was able to provide the requested documentation during the time of the inspection.
Plan of Correction:	1. CPR/First Aid class has been scheduled for 3/14/24. Staff who required refresher training have been enrolled. 2. Quarterly CPR/First Aid classes at the facility have been scheduled in advance to ensure new hires receive training and existing staff remain current. 3. A quarterly review of personnel files has been scheduled to ensure certification and trainings remain current. 4. All new hire files will be submitted to the Assistant Director for review by the end of the business day. The Assistant Director will maintain a list of new employees who require training.
Standard #:	22VAC40-73-290-B
Complaint related:	No
Description:	Based on observation, the facility failed to ensure the posting of the name of the current on-site person in charge. Evidence: 1. On the date of the inspection 2/12/2024, there was no posting of the on-site person in charge. 2. Staff member #4 acknowledged there was no posting.
Plan of Correction:	1. Person in charge has been posted. 2. Director of Operations, Assistant Director of Operations, Office Manager will be responsible for updating posting on a daily basis.
Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on a review of resident records, the facility failed to ensure complete Uniform Assessment Instruments (UAIs) records were reviewed at least annually. Evidence: 1. The last UAI for Resident #15 was completed in 2020. 2. Staff #2 acknowledged the facility did not have a current UAI for the resident.
Plan of Correction:	1. A quarterly review of resident files has been scheduled to ensure UAI?s are consistently up to date. 2. The facility is in the process of purchasing an EMR, which will allow us to receive alerts when UAI?s are due to be renewed. Until then, a spreadsheet with renewal dates is being created to facilitate tracking UAI renewals.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on staff interview and review of a resident record, the facility failed to update the ISP (Individualized Service Plan) at least once every 12 months. Evidence: 1. The resident records for Residents #14 and #15 did not contain ISPs. 2. Staff # 2 acknowledged the residents did not have current ISPs.
Plan of Correction:	1. A quarterly review of resident files has been scheduled to ensure ISP?s are consistently up to date. 2. The facility is in the process of purchasing an EMR, which will allow us to receive alerts when ISP?s are due to be renewed. Until then, a spreadsheet with renewal dates will be created to facilitate tracking ISP documentation.
Standard #:	22VAC40-73-520-I
Complaint related:	No
Description:	Based on observations made during a tour of the building, the facility failed to ensure the current month's activity schedule shall be posted in a conspicuous location in the facility. Evidence: 1. During the on-site inspection on 2/12/2024, the posted activities calendar was observed to be for November 2023. 2. Staff # 3 acknowledged the activities calendar was not for the current month.
Plan of Correction:	1. The activity schedule was posted and will be posted monthly.
Standard #:	22VAC40-73-610-B
Complaint related:	No
Description:	Based on observation of facility postings the facility failed to ensure that menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents. Evidence: The posted menu for the month of February 2024 did not include snacks.
Plan of Correction:	1. Snacks were added to the menu postings.
Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes. Evidence: A review of the Controlled Medication Count Record for the medication carts #1, #2 and #3 for the month of February 2024 documented inconsistencies in staff signing off on control medication counts from shift to shift.
Plan of Correction:	1. Medication aides were re-educated on the process of accurately accounting for controlled substances at the change of shift. Staff were informed that inconsistencies in the mediation administration record would result in disciplinary action. 2. A process for a weekly review of the MAR is being established (i.e., nursing supervisor will audit the MAR on a weekly basis to identify errors and discrepancies and carry out counseling and/or disciplinary action as needed.
Standard #:	22VAC40-73-670-2
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure that an applicant, for registration as a medication aide, does not act as a medication aide on a provisional basis for longer than 120 days. Evidence: Staff #3?s staff record contained documentation that indicated their provisional medication aide status began September 13, 2023. No documentation was provided during the inspection to confirm that Staff #3 has successfully passed the required competency evaluation to become a medication aide.
Plan of Correction:	1. An electronic HR database has been implemented to streamline the process of tracking employee licenses and certifications, alerting us prior to the expiration date. 2. Personnel files will be audited on a quarterly basis.
Standard #:	22VAC40-73-680-B
Complaint related:	No
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: 1. On 12/8/2023, during an on-site medication cart audit, with Staff #3, the licensing inspector observed pre-poured medications for 13 residents. 2. Staff #3 acknowledged the medications had been pre-poured for the 11:00 am medication pass.
Plan of Correction:	1. Medication aides were re-educated on medication management policy, specifically that medications are not to be pre-poured and should remain in the pharmacy-issued container until administered to the resident. Staff were informed that observation of pre-pouring would result in disciplinary action.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on resident record review and review of the Medication Administration Record (MAR), the facility failed to have all items required by the Standards on the MAR. Evidence: 1. A review of Resident #14?s October 2023 MAR did not document the staff member who administered the resident?s Acetaminophen 500mg, Atorvastatin 40mg, Divalproex SOD DR 250 mg, Famotidine 20 mg, Metformin HCL 1,000 mg, Pregabalin 75 mg and Vitamin C on 10/29/23 and 10/30/23. The medication administration spaces on the MAR were blank and there was no further explanation for the missing information documented on the MAR. 2. The September 2023 MAR did not contain the initials of the staff member who administered medication to Resident #14 over 80 times. The medication administration spaces on the MAR were blank and there was no further explanation for the missing information documented on the MAR. 3. A review of Resident # 8?s December 2023 MAR was missing blood glucose numbers and units of insulin administered for 12/1, 12/3, 12/4, and 12/6. There was no further explanation for the missing information documented on the MAR.
Plan of Correction:	1. We have hired an LPN whose responsibility will be auditing and reviewing resident charts, physician orders, the MAR, and the medication cart supply. 2. We had an outside pharmacist complete an additional pharmacy oversight review on 3/14/24. They will continue to come quarterly, and reports will be reviewed by the LPN as well as the administrator.
Standard #:	22VAC40-73-680-M
Complaint related:	No
Description:	Based on observations made during the medication cart audit, the facility failed to ensure medications ordered for PRN administration shall be available. Evidence: 1. The December 2023 MAR for Resident #14 and physician?s orders indicate the resident has been prescribed Tramadol 50 mg to be administered by mouth every 8 hours as needed for pain. 2. A medication cart audit with Staff #3 determined there was no Tramadol on the cart to be administered to the resident. 3. Staff #3 acknowledged there was no Tramadol 50 mg for Resident # 14.
Plan of Correction:	1. We have hired an LPN whose responsibility will be auditing and reviewing resident charts, physician orders, the MAR, and the medication cart supply. 2. We had an outside pharmacist complete an additional pharmacy oversight review on 3/14/24. They will continue to come quarterly, and reports will be reviewed by the LPN as well as the administrator.