VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Glow Cares Assisted Living Facility
8150 Newman Drive
Mechanicsville, VA 23116
(240) 432-3427

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: April 9, 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 RESIDENt 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

Type of inspection: Renewal Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 1/9/24 10:30 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: 4 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: Required postings, medication storage/availability/administration, staff/resident interaction, facility maintenance and cleanliness, resident care, file documentation Additional Comments/Discussion: Inspected additional bedroom for request to increase capacity. Provider to forward floor plans, room measurements and documentation of approval from locality regarding proposed use 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 #:	22VAC40-73-250-D
Description:	Based on observation and record review, each staff did not submit the results of a risk assessment on or within seven days prior to the first day of work, documenting the absence of tuberculosis in a communicable form. Evidence: The documented date of hire for staff # 2 is 1-8-24. The risk assessment was documented as completed on 2-28-24.
Plan of Correction:	The Administrator and Manager will ensure that each staff member submit the results of a risk assessment on or within seven days prior to the first day of work, documenting the absence of TB in a communicable form.
Standard #:	22VAC40-73-310-H
Description:	Based on a review of four resident records, one resident was admitted and retained with a documented prohibited care need. Evidence: The physician documented a prohibited care need on the physical examination for resident # 1.
Plan of Correction:	The Administrator and Manager will ensure that the physician completing physical is aware that the intention for the resident is to be admitted into an assisted living facility and not a skilled nursing facility. The physician mistakenly documented a prohibited condition that the resident requires continuous licensed nursing care, under the impression that the box needed to be checked yes. Physician has been contacted on 4-10-24 and a new physical will be completed reflecting no prohibited conditions.
Standard #:	22VAC40-73-440-A
Description:	Based on observation and record review, each staff did not submit the results of a risk assessment on or within seven days prior to the first day of work, documenting the absence of tuberculosis in a communicable form. Evidence: The documented date of hire for staff staff # 2 is 1-8-24. The risk assessment was documented as completed on 2-28-24. Based on a review of four residents, all residents were not assessed using the uniform assessment instrument (UAI) prior to admission. Evidence: 1. The documented date of admission for resident #1 is 10-6-23. The UAI was documented as completed on 10-21-23. 2. The documented date of admission for resident # 2 is 7-17-23. The UAI was documented as completed on 10-21-23 3. The documented date of admission for resident # 3 is 7-27-23. The UAI was documented as completed on 10-21-23.
Plan of Correction:	The Administrator and Manager will ensure that a UAI is utilized and completed during the assessment process, prior to admission.
Standard #:	22VAC40-73-450-D
Description:	Based on a review of four resident records, hospice services provided were not included on the individualized service plan for two residents. Evidence: Residents # 2 and # 3 receive hospice care. Their service plans did not include the services provided by hospice.
Plan of Correction:	Administrator has updated the ISP for Resident #2 to reflect hospice care services, 4-10-24. Going forward the Administrator will ensure that hospice services are reflected in the ISP. Resident #3 was discharged from hospice services on 9-19-23, thus not reflected in the ISP. The previous hospice provider was contacted 4-11-24 for proof of service dates documentation. That document will be retained in Resident #3 records.
Standard #:	22VAC40-73-680-M
Description:	Based on observation, medication ordered for PRN administration was not available or stored at the facility. Evidence: Staff # 1 was asked and was unable to find Morphine ordered for PRN administration for resident # 2 in the medication cart.
Plan of Correction:	Manager sent expired medication to the pharmacy to dispose of, with intentions of receiving more medication in return. The manager spoke with hospice nurse on 4-10-24 concerning the medication. The hospice nurse apologized for not submitting the order earlier and medication is expected to arrive at the facility by 4-11-24. The PRN hospice medication was delivered on 4-11-204. Administrator and manager will ensure that all PRN medications are on site and available for administration.
Standard #:	22VAC40-73-720-A
Description:	Based on a review of four resident records, a written Do Not Resuscitate Order (DNR) was not included in the individualized service plan for one resident. Evidence: The service plan for resident # 2 did include the DNR order.
Plan of Correction:	Administrator has updated the ISP for Resident #2 to reflect the DNR order. Going forward, the Administrator will ensure that DNR orders are documented in ISP.