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 7, 2024

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 GROUND 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

None

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/07/2024 8:45am ? 10:45am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of participants present at the facility at the beginning of the inspection: 6 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with participants: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: The Licensing Inspector observed the residents during activities and meals. The following were reviewed at the time of inspection: Menus, activity calendars, emergency drills, fire drills. Additional Comments/Discussion: None 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov

Violations:

Standard #:	22VAC40-61-20-C
Description:	Based on record review, direct observation, and staff interview, the facility failed ensure all required processes, plans, policies and procedures are implemented. Evidence: 1.Resident 3 has a physician?s order for Metformin 500mg that?s states ?take 1 tablet by mouth 2 times daily with meals?. 2.Two licensing staff observed on the day of inspection the medication unavailable to administer as ordered. The communication log indicates the family was contacted on 06/03/2024 to refill the medication. 3. The facility medication management plan indicates on page 40, in procedures #4, ?the family?will be notified at least 7 days prior to the last dose to be administered?. 4. The Medication administration record shows that the last dose of Metformin was administered on 06/05/2024. 5. On 6/05/2024 the communication log states ?message left on Resident 3 daughters? phone that she is currently out of medication?
Plan of Correction:	The RN on duty sent the empty medicine bottle home with the participant on 6/7/24 and instructed her to return it on her next scheduled day. The RN on duty called and left a message for participant?s daughter again on 6/7/24 (3rd phone message left) and reminded her that a refill in needed. A reminder was written for all nurses in the communication book that when a participant is running low in medication our policy is to give the family a 7-day notice for refills. Each nurse will be given the medication management plan to read, review, and sign by 6/21/24