VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Generations Crossing
3765 Taylor Spring Lane
Rockingham, VA 22801
(540) 434-4901

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: June 30, 2021 , July 1, 2021 and July 2, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 ADMISSION, RETENTION, AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUNDS 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-80 THE LICENSE. 63.2 General Provisions. 63.2 Protection of adults and reporting. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

The center continued to use two different forms to document fire drills. Recommended all information be merged onto one form.

Comments:

A monitoring inspection was initiated on 6/30/2021 and concluded on 7/2/2021. The director was contacted by telephone to initiate the inspection. The director reported that the current census was eight. The inspector emailed the director a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed three resident records, three staff records, selected sections of one additional resident and three staff records, activities calendar, menu, staff schedule, limited liability insurance and fire drills submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 7/2/2021. An exit interview was conducted with the director on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-61-300-A
Description:	Based upon documentation and an interview, the center failed to ensure the medication management plan was implemented for one of the three participant records reviewed. EVIDENCE: 1. On 7/2/2021 at approximately 11:00 am, the licensing inspector (LI) reviewed the medication administration records (MARs) with the current physician's orders (signed 1/12/2021) for participant 4. The July MAR listed Sinemet; however, the current list of medications did not list Sinemet. 2. The last Sinemet order on file for participant 4 was signed by the physician on 11/17/2020. 3. On 7/2/2021, participant 4's physician's office was contacted and the nurse stated the Sinemet order was still current and should have been on the updated list of medications. 4. The center's medication management plan states on page 37, "Medication orders will be transcribed to MARs by licensed nurse when received. Within 24 hours or on the next business day, a different licensed nurse will review the medication order for accuracy."
Plan of Correction:	On the annual health and physical (H & P) dated 1/8/21, the physician did not include the Sinemet on the list of current medications. There was no harm to the participant because he continued to receive the Sinemet. The physician was contacted on 7/2/21 for an order which is now in participant 4's medical record. Effective immediately all physicians' orders, including H & P and six month med reviews, will be reviewed by a registered nurse (RN). The nurse coordinator will review this policy with all RNs by the end of the business day on Wednesday 7/6/21.