VIRGINIA DEPARTMENT OF SOCIAL SERVICES

International Rejuvenation Center
221 West Main Street
Marion, VA 24354
(276) 782-1819

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: Dec. 7, 2021

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

Two licensing inspectors conducted an unannounced mandated monitoring inspection on 12/07/2021. The inspection began at 10:45 am and concluded at 1:00 pm. Resident files were reviewed and the noon medication pass was observed. Medication Administration Records, medications, and physician's orders were reviewed. A tour of the building and grounds was completed and lunch was observed. Residents were interviewed. The first aid kit was audited. The facility was providing care to 10 residents on the date of the inspection. Required posting's were observed in the facility. Areas of non-compliance are identified on the attached violation notice. An exit meeting was conducted with the administrator of the facility on 12/07/2021 and the findings were reviewed. The opportunity was given to find items that were not available in the record during the inspection. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days (12/25/2021)of receipt. If you have any questions or concerns, please feel free to contact your inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-210-G
Description:	Based on documentation review of staff records, the facility failed to maintain documentation of the number of hours of annual training available for each staff member. EVIDENCE: 1. Staff # 2 hired on 11/29/1997; he attended trainings on 04/19/2021, 05/19/2021, 05/24/2021, and 06/30/2021. The number of hours for all trainings attended was not documented in the file. 2. Staff #1 hired on 09/10/1997; he attended trainings on 04/19/2021, 05/19/2021, 05/24/2021, and 06/30/2021. The number of hours for all trainings attended was not documented in the file. 3. Staff #3 hired on 11/29/1997; she attended trainings on 04/19/2021, 05/19/2021, 05/24/2021, and 06/30/2021. The number of hours for all trainings attended was not documented in the file.
Plan of Correction:	Details were emailed to Licensing Inspector. Administer will monitor [sic]
Standard #:	22VAC40-73-260-A
Description:	Based on observations made during review of staff records, the facility failed to have documentation/certification of one staff person who has current certification in first aid. EVIDENCE: 1. Staff #2 hired on 11/29/1997 did not have current certification in first aid available in his staff record. 2. Staff #1 hired on 09/10/1997 did not have current certification in first aid available in his staff record. 3. Staff #3 hired on 09/10/1997 did not have current certification in first aid available in her staff record. 4. Staff # 1, 2, & 3 are the only direct care staff that work in the facility. At the time of inspection the facility did not have any direct care staff that had current first aid certification.
Plan of Correction:	Trainings will be updated. [sic]
Standard #:	22VAC40-73-260-B
Description:	Based on observations made during review of staff records, the facility ailed to have documentation/certification of one staff person at all times who has current certification in Cardiopulmonary resuscitation (CPR) from within the last two years. EVIDENCE: 1. Staff #2 hired on 11/29/1997 did not have current certification in CPR available in his staff record. 2. Staff #1 hired on 09/10/1997 did not have current certification in CPR available in his staff record. 3. Staff #3 hired on 11/29/1997 did not have current certification in CPR available in her staff record. 4. Staff 1, 2, & 3 are the only direct care staff that work in the facility. At the time of inspection the facility did not have any direct care staff that had current CPR certification.
Plan of Correction:	Trainings will be updated. [sic]
Standard #:	22VAC40-73-290-A
Description:	Based on observations made of required posting during the morning tour of the building, the facility failed to implement a procedure for posting the name of the current on-site person in charge. EVIDENCE: 1. The LI did not observe a posting with the name of the current on-site staff person in charge. When asked Staff #1 stated the name was not currently posted.
Plan of Correction:	Person in charge name was added same visit. [sic]
Standard #:	22VAC40-73-610-B
Description:	Based on observations made of the posted menu, the facility failed to have any menu substitutions recorded on the posted menu. EVIDENCE: 1. Hot pockets, pinto beans and pudding was listed for lunch on the day of inspection on the posted menu. The LI observed residents having hamburgers from Burger King for lunch. Staff #1 stated there was a change in the lunch menu due to work being done in the kitchen to address a drain issue. The lunch substitution was not recorded on the posted menu.
Plan of Correction:	Substitution was done only 10 minutes before added to menu. Administrator will monitor. [sic]
Standard #:	22VAC40-73-750-E
Description:	Based on observations made of resident rooms, the facility failed to have bed linens in good repair so that residents always have clean sheets, pillow cases, blankets and bedspreads. EVIDENCE: 1. The pillow case on Resident #3?s bed was observed to be dirty, dingy and have a large dark colored stain. The sheets and blanket on Resident #3's bed appeared to be dirty and dingy. 2. The pillows on Resident # 1's bed were worn, dirty and dingy and her blanket appeared to be dirty and stained. 3. The sheets and bedspread on Resident #2's bed appeared to be dirty, worn and dingy. Her sheets had what appeared to be bedbugs stuck to them and crawling around
Plan of Correction:	Arranged. Staff will continue to monitor. [sic]
Standard #:	22VAC40-73-870-B
Description:	Based on observations made during the morning tour of the building, the facility failed to ensure all areas were well-ventilated and free from foul odors. EVIDENCE: 1. Upon entering the building the LI noticed a strong sulfur smell. Facility staff stated there was a drain issue in the kitchen that extended into one of the common bathrooms. The odor was present for the duration of the inspection.
Plan of Correction:	The resident room was cleaned and will be maintained. Administrator will follow odor. [sic]
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during the morning tour of the building, the facility failed to keep all furnishings, including furniture, toilets, and showers clean and on in good repair. EVIDENCE: 1. Three of the vinyl seat covers on the chairs in the common living room were torn down the middle. 2. The chest of drawers belonging to Resident #2 had three out of four drawers broken and shoved in sideways off of the tracks. The drawers were not able to be pulled out. The top left drawer in the dresser belonging to Resident #2 was broken and sideways off of the track and could not be pulled out. 3. There was a dried white substance splattered on the front of the dresser belonging to Resident #1 and down the side of the headboard of her bed. 4. In the common bathroom located off of the dining room the wall siding along the bottom of the shower had come loose from the wall and hanging sideways. The toilet seat lid in this bathroom was observed to have cracked and chipping paint. 5. The toilet seat in the common bathroom numbered B-3 was observed to have cracked and chipping paint. 6. In the common bathroom located across from the front desk was observed to have a missing ceiling tile above the shower and the bathmat in the shower appeared to be dirty, dingy and have a ring of black mold on it.
Plan of Correction:	All furnishings being replaced and repaired. All repair will be completed. Staff will monitor regularly. [sic]
Standard #:	22VAC40-73-950-B
Description:	Based on an interview with staff, the facility failed to include in their emergency preparedness and response plan a description of the on-site emergency generator?s capacity to provide sufficient power for the operation of lighting, ventilation, temperature control, supplied oxygen and refrigeration. EVIDENCE: 1. When asked about an on-site emergency generator, Staff #1 stated ?there is a large on-site generator but I am unsure of the generator?s capacity to be able to provide sufficient power for the operation of lights, ventilation, temperature, oxygen and refrigeration.?
Plan of Correction:	Will contract as per requirement. Administrator will follow regularly. [sic]
Standard #:	22VAC40-73-980-H
Description:	Based on observations made of the facility?s supply of emergency food and drinking water, the facility failed to have at least 48 hours of the supply of emergency drinking water on-site at any given time, of which the facility?s rotating stock may be used. EVIDENCE: 1.There was a total of 40 bottles containing 16.9 ounces on site the day of inspection for 10 residents and 3 staff.
Plan of Correction:	Extra water was added and staff will monitor. [sic]