VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Generations Central
318 S West Street
Culpeper, VA 22701
(540) 403-0557

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Sept. 26, 2024

Complaint Related: No

Areas Reviewed:

General Provisions Administration Personnel Supervision Admission, Retention and Discharge Programs and Services Building and Grounds Emergency Preparedness

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: 09/26/2024 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: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: LI observed residents participating in activity programs and eating lunch. This LI also observed medications being administered to a participant. Additional Comments/Discussion: 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov

Violations:

Standard #:	22VAC40-61-50-E
Description:	Based on participant record review, the center failed to ensure participant?s, or their legal representative annually review the rights and responsibilities of participants. Evidence: Participant 2?s (admitted on 3/15/2022) last documented review of Participant rights and responsibilities was on 3/29/2023.
Plan of Correction:	Staff reviewed the Participant Rights with Participant 2 and Participant 2 signed documentation of this review. Additionally, staff reviewed all charts to ensure that Participant Rights have been annually reviewed with each Participant or their legal guardian (when applicable).
Standard #:	22VAC40-61-230-D
Description:	Based on participant records review, the center failed to address all identified needs the participant?s plan of care. Evidence: 1. Participant 2?s (admitted on 3/15/2022) Participant Physical Exam dated 11/30/2023 lists under Special Diets, no peanuts or other nuts. 2. Participant 2?s Plan of Care, completed on 7/19/2024, does not list the physician?s special diet order for no peanuts or other nuts.
Plan of Correction:	Participant 2?s Plan of Care was updated to include that the participant cannot eat nuts. All staff was notified of this addition. The special diet list posted in the kitchen was reviewed and this dietary restriction was already listed
Standard #:	22VAC40-61-250-B
Description:	Based on participant records review, the center failed to ensure the participant record included a current photograph or narrative physical description of the participant. Evidence: 1. Participant 1?s participant record, who was admitted to the program on 9/19/2024, did not contain a narrative physical description or current photograph. 2. Staff 3 stated a photo had not yet been obtained.
Plan of Correction:	When the participant arrived at the Center the following morning, a photo was taken and placed in the participant?s chart. Staff have updated the enrollment checklist to ensure that a participant?s photo is taken on their first day at the Center and added to their chart.
Standard #:	22VAC40-61-300-E-2
Description:	Based on direct observation and participant record review, the center failed to ensure all medication shall be labeled with participant?s name, the name of the medication, the strength and dosage amount, the route of administration, and the frequency of administration. Evidence: 1. Participant 3 had a prescription bottle for Carbidopa-Levo ER 25-100 tab, the label stated `Please see attached for detailed directions?. 2. The label did not include the route of administration or the frequency of administration. 3. Picture Evidence.
Plan of Correction:	Participant 3?s Carbidopa-Levo ER 25-100 tab was discharged and sent home with the caregiver. It was requested that they provide a prescription bottle with complete instructions including the route and frequency of administration to align with the medication order on file. The participant discharged for unrelated reasons before the corrected prescription was provided.
Standard #:	22VAC40-61-300-E-7-d
Description:	Based on participant record review the center failed to ensure the Medication Administration Record (MAR) included all required information by the standards. Evidence: 1. Participant 3?s September 2024 MAR did not include the reason the Carbidopa-Levo(Sinemet) ER 25-100 mg tab was prescribed or the date medication was prescribed. 2. Participant 2?s September 2024 MAR did not include the reason for the medication, the route of the medication or when the medication was prescribed for Tylenol Arthritis Pain ER 650 mg and Ibuprofen 200 mg.
Plan of Correction:	The Nurse Coordinator updated all MAR sheets for all participants to ensure that the reason for the medication and the date it was prescribed are clearly listed and matched the doctor?s order on file.
Standard #:	22VAC40-61-300-G
Description:	Based on participant record review, the center failed to obtain specifics of symptoms, dosage, timeframes, and directions as to what to do if the symptoms persist when PRN medication is administered by a medication aide to a participant that is not capable of determining whether the medication is needed. Evidence: 1. Participant 2 has an order for Ibuprofen 200 mg (prescribed 9/11/2024) for pain every 6 hours and Tylenol Arthritis Pain 650 mg (prescribed 9/11/2024) for chronic pain every 6 hours, but no directions for use if symptoms persist.
Plan of Correction:	The medication order form was returned to the participant/caregiver, and it was requested that they ask the doctor to review and complete the form to include directions for use if the symptoms persist. The medication was not administered until a completed medication order form was returned to the Center.
Standard #:	22VAC40-61-520-C
Description:	Based of center records review and staff interview, the facility failed to implement a semi-annual review on the emergency preparedness and response plan for all staff, participants and volunteers. Evidence: Staff meetings were held on 11/20/2023 and 8/14/2024 in which `Emergency Policy Review? was written on the Staff Meeting Notes document.
Plan of Correction:	To formalize the emergency preparedness plan review, staff will create a video outlining the plan and individual responsibilities for staff and volunteers. Staff and volunteers will review the video every 6 months, and this will be documented. Additionally, staff will review the emergency plan with participants during morning meeting every 6 months. This will also be documented.
Standard #:	22VAC40-90-30-B
Description:	Based on staff records review, the center failed to meet the requirements specified in the Regulation for Background Checks for Assisted Living Facilities and Adult Day Centers. Evidence: Staff 1 (hired 1/24/2024) had an incomplete Sworn Statement in the staff member?s staff record. Question 2 was not answered.
Plan of Correction:	During the inspection, the staff member reviewed the form and stated that she missed checking the box. She immediately corrected it.