VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bickford of Virginia Beach
2629 Princess Anne Road
Virginia beach, VA 23456
(757) 821-0198

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: Sept. 11, 2024 , Sept. 13, 2024 and Sept. 16, 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 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal An on-site Renewal Inspection was conducted on 9-11-24 (Ar 07:20 am/Dep 18:10); 9-13-24 (09:30/ Dep 18:20) and 9-16-24 (Ar 09:20/Dep 18:25). Breakfast meal was observed on Day 1, emergency documents, fire drills, water temperature, first aid kit and emergency food and water items were completed. Resident and staff records reviewed, medication pass observation was also conducted. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure a staff person on or within seven days prior to the first day of work at the facility submitted the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. On 9-13-24, during staff record reviews with staff #1, staff #6?s record did not have documentation of the absence of TB in a communicable form. The TB document from a local medical facility dated 8-10-23 documented the staff to ?return to have Tb skin test read between 48-72 hours?return for reading between Saturday 08/12/23 at 05:15 PM and NO LATER THAN 04:45 PM on 08/13/23?. Staff?s date of hire noted as 8-11-23. 2. Staff #1 and #6 acknowledged there was no documentation of the absence of TB within the required time prior to the first day of work.
Plan of Correction:	*Staff #6 had a negative TB Screening completed on 6/20/2024 *All existing staff from 6/20/2024 or prior have a negative annual TB screening on file, and all staff hired after 6/20/2024 have either a negative TB screening or PPD on file *Moving forward, unless contraindicated, all new hires will be screened for active TB by authorized licensed nurses at the Branch within but not later than 7 days of hire. Person Responsible: Exec. Dir., Health & Wellness Director/ Coordinator Target Completion Date: 10/4/24
Standard #:	22VAC40-73-260-C
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the listing of all staff who have certification in first aid or cardiopulmonary resuscitation (CPR) was kept up to date. Evidence: 1. On 9-13-24, the inspector inquired of staff #5 where the First Aid/CPR listing was posted. Staff point to the wall across from the medication room near the nurse?s station on the assisted living unit of the building. Staff #7 came to the area at the same time and ask if the inspector needed help. The inspector pointed to the FA/CPR listing and showed both staff members, the listing which was updated by staff #7 on 9-10-24. The posted list included names of staff with dates that are were not current. Staff #8?s card expired 7-24-24, staff #9?s card expired 9-7-24 and staff #10?s card expired 3-7-24. 2. Staff # 5 and #7 acknowledged the First Aid/CPR listing was not kept up to date.
Plan of Correction:	*The First Aid/CPR Listing was updated on 9/13/24 to reflect only staff members with current certification, to include staff member #10 who had just provided current certification on 9/13/24. *All staff, at the time of hire, who do not have current CPR will be educated on the need to obtain it within 60 days. Those who are Direct Care Staff will also be required to either have or obtain First Aid within 60 days of hire. *The list will be updated at the beginning of each month, and those with certifications that expire at the end of that month will be notified of the need to renew before expiration. Person Responsible: Executive Dir. & Admin. Asst. Target Completion Date: 9/13/24 Ongoing
Standard #:	22VAC40-73-310-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a documented interview between the administrator or a designee responsible for admission and retention decisions, the individual, and the legal representative, if any, was completed. Evidence: 1. On 9-11-24, record review with staff #1 and #2, resident #1 (date of admit 8-27-24) and #3 (date of admit 12-7-23) record did not have documentation of an interview. 2. Staff #1 and #2 acknowledged the residents record did not have documentation of an interview.
Plan of Correction:	*Residents #1 and #3 had their Interview Date added to their Mental Health Screening Form. That date will be the date of the pre-admission assessment. *All remaining resident records will be audited to assure that there *Residents #1 and #3 had their Interview Date added to their Mental Health Screening Form. That date will be the date of the pre-admission assessment. *All remaining resident records will be audited to assure that there is a Mental Health Screening Form and that it contains the date of the Interview. *New admission eCharts will be audited within 1 week to assure that this form is on file and contains that date. Person Responsible: Health & Wellness Dir./Coord., Exec. Dir. or Designee Target Completion Date: 10/10/24
Standard #:	22VAC40-73-310-H
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with a prohibitive condition or care needs. Evidence: 1. On 9-11-24, during medication pass observation with staff #4, resident #4 was administered Escitalopram (Lexapro). The resident?s September 2024 medication administration record (MAR) and physician order dated 8-1-2024 noted Lexapro. The record did not include a psychotropic treatment plan for this medication. 2. On 9-11-24, during medication pass observation with staff #4, resident #6 was administered Trazadone. The resident?s September 2024 MAR and physician?s orders dated 8-9-24 noted resident prescribed Lorazepam (Ativan), Paroxetine (Paxil) and Quetiapine (Seroquel) and Trazadone. The record did not include a psychotropic treatment plan for Paroxetine and Lorazepam. 3. Resident #7 was administered Buspirone (Buspar) during medication pass observation with staff #6. The resident?s September 2024 MAR and physician?s orders dated 8-9-24 noted resident prescribed Quetiapine (Seroquel), Alprazolam (Xanax)and Buspirone. The resident?s record did not include a psychotropic treatment plan for these medications. 4. Resident #8?s was administered Trazadone and Quetiapine (Seroquel) during the medication pass observation with staff #6. The resident?s September 2024 MAR and physician?s orders dated 8-2-24 noted resident prescribed Buspirone (Buspar), Mirtazapine (Remeron), Quetiapine, Risperidone (Risperdal), Sertraline (Zoloft), Trazadone and Lorazepam (Ativan). The resident?s record did not include a psychotropic treatment plan for these medications. 5. On 9-16-24, during medication record review with staff #1, resident #3?s September 2024 MAR noted resident administered Sertraline (Zoloft). The resident?s physician?s order dated 8-9-24 noted resident prescribed Sertraline. The resident record did not include a psychotropic treatment plan for this medication. 6. Staff #1 acknowledged the residents record did not include a psychotropic treatment for psychotropic mediations as required.
Plan of Correction:	*Residents #4, #6, and #7 now have Psychoactive Treatment Plans for the medications identified. *A list of all residents with orders for Psychoactive medications will have their eCharts audited to assure that there is a treatment plan for each medication. *Each Provider will receive a blank Psychoactive Treatment Plan form with each new prescription received. *All eCharts will be audited weekly during the Med Variance Audits for compliance Person Responsible: Health & Wellness Dir./Coord. Target Completion Date: 10/10/24
Standard #:	22VAC40-73-325-B
Description:	Based on record review and staff interviewed, the facility failed to ensure the resident?s record include documentation of a fall risk assessment. Evidence: 1. On 9-11-24, during record review with staff #2, resident #2?s record did not have documentation of an annual fall risk assessment. A review of resident?s clinician notes dated 8-17-24 at 08:06 AM, the resident?s record noted a fall with skin tear to the left arm. The record did not have documentation of an assessment following a fall. 2. On 9-11-24, during record review with staff #2, resident #3?s record did not have documentation of an initial fall risk assessment. Resident #3 assessed at the assisted living level of care and the resident?s date of admit noted as 12-7-23. The staff presented an assessment that was dated 9-11-24. 3. On 9-16-24, during record review with staff #1, resident #7?s fall risk assessment provided was dated 3-25-24. The resident?s clinical notes documented falls on 4-13-24 at 05:05 AM?resident observed walking in the courtyard. All of a sudden resident was observed on the ground lying on back by the table and chairs?no injuries noted. Clinical notes documented on 4-11-24 at 09:00 AM, unwitnessed fall?resident found on floor in room next to sink on floor?resident complained of right shoulder and right hip pain and chest pain. The resident was sent out to ER. Clinical notes documented on 4-4-24 at 12:30 AM, resident was heard yelling for help by another resident; resident observed on the floor lying on left side behind the door?right side of resident?s head appeared to be swollen and sore when touched?resident sent out to the ER. The fall risk assessment provided was dated 3-25-24. There were no assessments for the falls noted in the record. 4. Staff acknowledged that the risk assessment for the residents were not completed as required.
Plan of Correction:	*Residents #2, #3, & #7 each have current Fall Risk Assessments in their eCharts. *All eCharts for Assisted Living residents will be audited to assure that they contain a current Fall Risk Assessment/Post Fall Risk Assessment. Those without will be assessed and the form marked as ?completed as a part of a plan of correction ? 9/27/24? * New admission eCharts for Assisted Living residents will be audited within 1 week to assure that this form is completed and on file. Person Responsible: Health & Wellness Dir./ Coord., Exec. Dir., Admin. Asst. Target Completion Date: 10/31/24
Standard #:	22VAC40-73-380-B
Description:	Based on record review and staff interviewed, the facility failed to ensure the personal and social data for a resident is in the resident?s record. Evidence: 1. On 9-11-24 during record review with staff #2 and on 9-16-24 during record review with staff #1, resident #3?s record did not have documentation of a completion of a personal and social data document with the required information. 2. Staff #2 acknowledged the resident?s personal and social data record was not in the resident?s record.
Plan of Correction:	*Resident #3 Face Sheet & Social Data forms were completed in their entirety to include information on vocation. *All resident files were audited to assure that each contained a Face Sheet & Social Data forms that include the vocation. Those with missing information will be resent to the POA, electronically in August Health, to be completed in its entirety. *All new admissions will have a eChart audit within 1 week of move in to ensure that these forms are complete with no missing information. Person Responsible: Exec. Dir., & Admin. Asst. Target Completion Date: 10/32/24
Standard #:	22VAC40-73-410-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it obtained acknowledgement of having provided orientation to the resident or legal representative and kept a copy in the resident?s record. Evidence: 1. On 9-11-24, during record with staff #1 and #2, resident #1?s record did not have documentation of having received orientation to the facility as a new resident. 2. Staff #1 and #2 acknowledged the resident?s record did not have documentation of an orientation to the facility.
Plan of Correction:	*Resident #1 POA did not complete/return all of the eChart admission forms prior to move in. This was not discovered until after move in. This form was reviewed with him, and his mother, and signed/dated/uploaded. The form will be marked ?completed as a part of a plan of correction ? 9/27/24? *All pending admissions will have all Aug. Health move-in paperwork sent electronically. They will be instructed to read but not to complete until a week prior to the planned move in date. They will also be reminded that there can be ?no blanks? in the paperwork. *Within 2 days of anticipated move in of new residents, outstanding Tasks in Aug. Health will be reviewed. The POA will be reminded that all outstanding tasks must be completed prior to move-in with some requiring review in person during the day of move-in. *New admission eCharts will be audited within 1 week following move in to assure that this form is complete and on file. Person Responsible: Exec. Dir., & Admin. Asst. Target Completion Date: 10/31/24
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a resident individualized service plan (ISP) was completed. Evidence: 1. On 9-11-24 during record review with staff #2, resident #1?s record did not have documentation of a preliminary plan of care or a comprehensive plan of care with resident?s assessed needs prior to and following admission to the facility The resident?s date of admission was noted as 8-26-24. 2. Staff #2 acknowledged resident #1 did not have an Individualized Service Plan for resident #1.
Plan of Correction:	*Resident #1 to have her comprehensive ISP completed, reviewed, signed, and uploaded by 10/10/24 and marked as ?completed as a part of a plan of correction ? 9/27/24? *All other resident records will be audited to assure that each has an initial ISP that has been reviewed, signed, and uploaded into Aug. Health *All future admissions will be assessed prior to move in. That assessment will be used to complete the initial ISP that will be reviewed with the POA and resident (when appropriate) on the day of move in. *New admission eCharts will be audited within 1 week of move-in to assure that the initial ISP has been reviewed, signed, dated and uploaded into the eChart. Person Responsible: Health & Wellness Dir./Coord, Exec. Dir. & Admin. Asst. Target Completion Date: 10/31/24
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs, including reviews and updates. Evidence: 1. On 9-11-24 during record review with staff #2, resident #2?s uniformed assessment instrument (UAI) dated 6-1-24 noted dressing as mechanical help (mh). The ISP noted staff was to provide resident with assistance undressing for bathing. The resident is assessed as being oriented. The ISP noted resident is unaware of place and time, forgets information?resident might plan activities but is unable to recall the time?redirection and orient as needed. 2. On 9-11-24 during record review with staff #2, resident #3?s date on admit was noted 12-7-23 and the initial ISP was dated 3-11-24 by the developer, staff #2, and 6-10-24 by the legal representative and staff #1. The review date for the service plan was dated 06/2024. Resident #3?s record did not include an updated individualized service plan. 3. 09-16-24 during record review with staff #2, resident #6, UAI dated 9-5-24 noted transfer need assessed as mechanical help/human help/physical assistance. The individual service plan noted resident transfers from seated position to standing by using the arms of chair or couch?resident transfers with mechanical assistance of chair arms and grab bars. The ISP noted resident occasionally wanders into different resident?s room?resident will be redirected and given task with an activity of interest. The resident?s UAI did not note this assessed need. 4. Staff #1 acknowledged the residents? record did not include all assessed needs.
Plan of Correction:	*Resident #2 will be reassessed in the areas of dressing and orientation to assure that his needs are accurate and match on the UAI and ISP. It will be reviewed with the POA/resident/signed/dated/uploaded into Aug. Health. *Resident #3 ISP and UAI updated to reflect resident?s current needs. It will be reviewed with the POA/resident/signed/dated/uploaded into Aug. Health. *Resident #6 ISP to be updated to reflect current needs with transfers and behaviors regarding wandering. UAI also to be updated to reflect those needs. It will be reviewed with the POA/resident/signed/dated/uploaded into Aug. Health. *These forms will be marked as ?completed as a part of a plan of correction ? 9/27/24? *A 2 person cross-check between the UAI & ISP will be completed, for accuracy. Any error noted will be corrected prior to the resident/POA receiving it for signature. Person Responsible: Health & Wellness Dir./Coord, Exec. Dir. & Admin Asst. Target Completion Date: 10/31/24
Standard #:	22VAC40-73-550-G
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the rights and responsibilities of residents were reviewed with residents. Evidence: 1. On 9-11-24 during record review with staff #2 and on 9-16-24 with staff #1, resident #2?s record did not have documentation of an annual review of the rights and responsibilities of residents in an assisted living facility. The resident?s date of admit was noted as 12-23-22. 2. On 9-16-24 during record review with staff #1, resident #8?s record did not have documentation of an annual review of the rights and responsibilities of residents in an assisted living 3. Staff #1 acknowledged the resident?s record did not have documentation of the annual rights review.
Plan of Correction:	*Needed corrections to the Resident Rights form was communicated to August Health. *Resident #2 completed an annual Resident Right?s Review on 10/4/2024. The form was uploaded into Aug. Health. *All other residents will complete an annual Resident Rights review in Aug. Health once the form has been corrected. Otherwise, it will be done on paper and uploaded. *October will be designated and scheduled as the month for the annual Resident Rights Review. Person Responsible: Exec. Dir., Happyness Coord. & Admin. Asst. Target Completion Date: 10/31/24
Standard #:	22VAC40-73-640-A
Description:	Based on record review and staff interviewed, the facility failed to ensure each resident?s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: 1. On 9-16-24, during the record review with staff #1, resident #8?s physician?s order dated 8-2-24 noted resident prescribed Risperidone (Risperdal) twice a day, original date noted 7-3-24. This resident?s September 2024 medication administration record (MAR) did not include this medication. A check of the resident medication supply was conducted, the medication was not available in the facility for administration. Staff #1 acknowledged, resident #8?s medication ordered was not available for administration.
Plan of Correction:	*Resident #8 has a signed order in the Aug. Health eChart from prescriber, dated 7/3/24 for tapered dosing that reads as follows, ?Resperidone 0.25mg po 9am & qhs x 4 d, then 0.5mg po qam & qhs x 4 d, then 0.5mg po qam & 1mg po qhs x 4 d, then 1mg po qam & qhs for depression/anxiety/paranoia? *Resident #8 also has a comprehensive Provider note, dated 7/3/24 in the Aug. Health eChart, explaining the process of tapering the doses between the Resperidone and the Zyprexa, and instructions regarding discontinuation. The medication was not on hand on 9/16/24 because it had already been discontinued. These documents were located on 10/3/24 on the eChart by Staff #2, who was not present for this portion of the inspection. *Additional instructions will be provided to staff responsible for scanning documents into the eChart to improve to process of locating scanned documents. *eCharts have a large number of scanned documents. When at all possible and available, the HWD/HWC will participate in locating the requested documents, as they are the most familiar with the medical contents of the medical records. When not available, more time will be needed for non-clinical staff to search for the requested clinical forms. Person Responsible: Health & Wellness Dir./Coord., Exec. Dir. & Admin. Asst. Target Completion Date: 10/3/2024
Standard #:	22VAC40-73-650-B
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the physician or other prescriber?s orders included all required information. Evidence: 1. On 9-16-24, resident #2?s physician?s orders and medication administration record (MAR) review was conducted with staff #1. Resident #2?s physician?s orders dated 8-9-24 did not include diagnosis, condition, or specific indication for Nuretin Omega 3 capsule being administered. 2. Resident #5?s Furosemide (Lasix) noted on the physician?s order dated 8-19-24 did not include a diagnosis, condition, or specific indication for the prescribed medication. 3. Resident #6?s Calcium/Vitamin D, Probiotic capsule, and Polyethene Glycerin Powder (Miralax) noted on the physician?s order dated 8-9-24 did not include a diagnosis, condition, or specific indication for the prescribed medications. 4. Resident #7?s Amiodarone (Pacerone) and Guaifenesin noted on the physician?s order dated 8-9-24 did not include diagnosis, condition, or specific indication for the prescribed medications. 5. Resident #8?s Midorine noted on the physician?s order dated 8-2-24 did not include diagnosis, condition, or specific indication for the prescribed medication. 6. Staff #1 acknowledged the residents? records did not include the diagnosis for prescribed medications noted on the physician?s order and medication administration records.
Plan of Correction:	*Resident #2 had the diagnosis added for the Nutretin Omega 3 capsule. *Resident #5 had the diagnosis added for the Lasix *Resident #6 had the diagnosis added for the Calcium/Vit D and the Polyethene Glycerin Powder. Resident #7 had the diagnosis added for the Amiodarone and Guaifenesin. Resident #8 had the diagnosis added for the Midorine. *All admission orders or new orders will also contain the diagnosis/condition/indication for use at the time the order is received and prior to sending to the pharmacy to be profiled. *HWD/HWC will monitor this weekly during their medication variance audits. Person Responsible:Health & Wellness Dir./Coord Target Completion Date: 10/10/24
Standard #:	22VAC40-73-680-I
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the medication administration record (MAR) included all required information. Evidence: 1. On 9-16-24, resident #2?s September 2024 MAR review with staff #1 did not include diagnosis, condition, or specific indication for Nuretin Omega 3 capsule. 2. On 9-16-24, resident #5?s September 2024 MAR review with staff #1 did not include diagnosis, condition, or specific indication for Furosemide (Lasix). 3. On 9-16-24, resident #6?s September 2024 MAR review with staff #1 did not include diagnosis, condition, or specific conditions for Calcium/Vitamin D, Probiotic capsule, Tramadol, Polyethene Glycerin Powder (Miralax), and Senna-Plus. 4. On 9-16-24, resident #7?s September 2024 MAR review with staff #1 did not include diagnosis, condition, or specific indication for Amiodarone (Pacerone) and Guaifenesin. 5. On 9-16-24, resident #8?s September 2024 MAR review with staff #1 did not include diagnosis, condition, or specific indication for Docusate Sodium Liquid (Colace) and Midorine (Proamatine). 6. Staff #1 acknowledged the resident?s medication administration record did not include diagnosis, condition, or specific conditions for medication, supplement prescribed.
Plan of Correction:	*Resident #2 had the diagnosis added for the Nutretin Omega 3 capsule. *Resident #5 had the diagnosis added for the Lasix *Resident #6 had the diagnosis added for the Calcium/Vit D and the Polyethene Glycerin Powder. Resident #7 had the diagnosis added for the Amiodarone and Guaifenesin. Resident #8 had the diagnosis added for the Midorine. *All admission orders or new orders will also contain the diagnosis/condition/indication for use at the time the order is received and prior to sending to the pharmacy to be profiled. *HWD/HWC will monitor this weekly during their medication variance audits. Person Responsible: Health & Wellness Dir./Coord. Target Completion Date: 10/10/24
Standard #:	22VAC40-73-680-K
Description:	Based on observation, record reviewed, and staff interviewed, the facility failed to ensure PRN medications ordered shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24 -hour period, and directions as to what to do if symptoms persist. Evidence: 1. On 9-11-24 during the medication pass observation with staff #4, resident #6?s September 2024 medication administration record (MAR) noted resident was prescribed Polyethene Glycerin Powder (Miralax), dissolve in 4-8 ounces water. The PRN order was not for an exact amount. The cup used to mix the powder and water was a 9 oz cup. 2. Staff #1 and #2 acknowledged the PRN medication requirement was not conducted.
Plan of Correction:	*Resident #6 Polyethene Glycerin Powder order was clarified with the Provider with regards to the exact amount of water to be mixed in with the powder. *All new orders will be reviewed, prior to sending to the pharmacy, to assure that there are no ranges contained in any of the orders received by the Provider. *To assist the staff who administer this medication, a liquid measuring cup will be used to pour the exact amount of water ordered into the 9 oz cup used to administer the medication to the resident. *The RMAs will be educated on this new process by the HWD/HWC. Person Responsible: Health & Wellness Dir./Coord. Target Completion Date: 10/10/24
Standard #:	22VAC40-73-680-M
Description:	Based on observation, record reviewed, and staff interviewed, the facility failed to ensure medications ordered for PRN (as needed) administration was available, properly labeled for the specific resident, and properly stored at the facility. Evidence: 1. On 9-11-24, following medication pass observation with staff #3, the prescribed PRNs noted on resident #2?s physician?s orders dated 8-9-24 and September 2024 medication administration record (MAR) were not available. Tylenol, Albuterol inhaler and Diclofenac gel were not available in the facility. 2. On 9-11-24, following medication pass observation with staff #4, the prescribed PRN noted on resident #6?s physician?s orders dated 8-9-24 and September 2024 MAR were not available. Trazadone, Tylenol, Melatonin and Senna-Plus were not available in the facility. 3. On 9-11-24, following medication pass observation with staff #4, the prescribed PRN noted on the resident #8?s physician?s orders 8-2-24 and September 2024 MAR were not available. Albuterol (Pro Air HFA), Tylenol and Senna Plus were not available in the facility. 4. Staff #1 and #2 acknowledged the residents? PRN medications ordered were not available in the facility.
Plan of Correction:	*Resident #2 had their Tylenol, Albuterol, and Diclofenac gel were discharged by the Provider. *Resident #4 had their Trazadone and Melatonin on the cart at the time of the cart inspection. The Tylenol and Senna Plus were re-ordered. *Resident #8 had their Albuterol, Tylenol, and Senna Plus on the med cart at the time of the inspection. They were filled prior to the inspection. *HWD/HWC to print a list of PRNs weekly and provide it to the RMAs to audit against the medications we have on hand to assure that all PRNs are available to be given, if needed. *HWD/HWC to review this at the time of their weekly medication variance audits. Person Responsible: Health & Wellness Dir./Coord. & RMAs Target Completion Date: 10/10/24
Standard #:	22VAC40-73-950-E
Description:	Based on documents reviewed and staff interviewed, the facility did not have documentation of the current semi-annual review on the facility?s emergency preparedness and response plan for all staff, residents, and volunteers. Evidence: 1. On 9-11-24, the facility?s documentation of the semi-annual review of its emergency preparedness and response plan for all staff, residents, and volunteers was dated 2-28-24. 2. Staff #1 acknowledged, the emergency preparedness and response plan were not conducted semi-annually as required.
Plan of Correction:	*The semi-annual review of the facility?s emergency preparedness and response plan will be completed will all staff, residents, and volunteers by the end of Oct. *The next semi-annual review will be scheduled on the Outlook calendar, at the first of the month, to be completed during that month. . *A sign-in form will be used to document those who participated Person Responsible: Exec. Dir., Maintenance Coord., & Happyness Coord. Target Completion Date: 10/31/24
Standard #:	22VAC40-73-970-E
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the fire and emergency evacuation drills included all the required information . Evidence: 1. On 9-11-24, a review of the facility?s fire and emergency evacuation drills dated 6-1-24 and 7-18-24 did not include the weather conditions. 2. Staff #1 acknowledged the fire and emergency documents did not include all required information.
Plan of Correction:	*The Maint. Coord. researched the weather conditions for the dates of 6/1/24 & 7/18/24 and added it to the Fire Drill Report. *The Maint. Coord will take the form used to document the Fire Drills and ?highlight? the directions where it says to document the current weather conditions at the time of the drill, as a reminder not to omit this information from the report. *A copy of all drills conducted by the Maint. Coord. will be provided to the Exec. Dir. for review and to be added to the Survey Binder. Person Responsible: Maintenance Coord. & Exec. Dir. Target Completion Date: 10/10/24
Standard #:	22VAC40-73-990-C
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained. Evidence: 1. On 9-11-24, a review of staff?s participation in an exercise in which the procedures for resident emergencies were conducted, dated 6-21-24 (missing person), did not include all staff on each shift. 2. Staff #1 acknowledged; the resident emergency practice conducted on 6-21-24 did not include all staff on each shift.
Plan of Correction:	*A resident emergency practice drill will be conducted before the end of Oct., and that drill will be practiced on all 3 shifts. *The next semi-annual review will be scheduled on the Outlook calendar, at the first of the month, to be completed during that month, to assure that it is completed every 6 months. *A sign-in form will be used to document those who participated on all 3 shifts. Person Responsible: Exec. Dir., Health & Wellness Dir./Coord. Target Completion Date: 10/31/24