VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Town & Country Adult Care Residence
60 Town & Country Drive
Lebanon, VA 24266
(276) 889-3222

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: Nov. 26, 2019

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 at Town & Country Adult Care Residence in Lebanon, Virginia on 11/26/2019. The inspection began at 10:15 am and concluded 1:30 pm. A tour of the building and grounds was conducted. Residents and collaterals were interviewed. Resident and staff interactions were observed. The noon meal and noon medication pass were observed. A sample of resident and staff files were reviewed. Medications, physician's orders, and Medication Administration Records were observed. The facility was found to be providing care to 20 residents the day of the inspection. Required postings and previous inspections were observed to be in place. An exit meeting was held with the administrator on 11/26/2019 and at that time the opportunity was given to find any items that were not readily available in the records. As a result of this inspection, three violations are being cited. A corrective action plan should be developed addressing steps to correct the noncompliance of each standard; measures to prevent the reoccurrence; and person(s) responsible for implementing each step and/or monitoring and prevention measures. The "description of action to be taken" for each violation, along with the "date to be corrected" must be returned to this licensing office signed and dated within 10 calendar days (12/14/2019) of receipt. If you have any questions or concerns please contact your licensing inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-290-A
Description:	Based on observations made during the morning tour of the building and the staff schedule posting, the facility failed to maintain a written work schedule that includes an indication of whomever is in charge at any given time. EVIDENCE: 1. The written staff schedule had the names of each staff person working during the month of November, but it did not show who was in charge at any given time.
Plan of Correction:	The provider's response(s) for the plan of correction was not received as of 12/14/2019 and will not appear on this violation notice.
Standard #:	22VAC40-73-290-B
Description:	Based on observations made during the morning tour of the building, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge. EVIDENCE: 1. There was no in-charge staff person posting. Staff # 3 stated she did not know this was a requirement would develop a posting for the in-charge staff person.
Plan of Correction:	The provider's response(s) for the plan of correction was not received as of 12/14/2019 and will not appear on this violation notice.
Standard #:	22VAC40-73-700-1
Description:	Based on review of Medication Administration Records (MAR's) and Physicians orders, the facility failed to ensure when oxygen therapy is provided the physician's order includes the oxygen source. EVIDENCE: 1. Resident # 9 is prescribed oxygen therapy 2 liters on an as needed basis. The Physician's order for her oxygen therapy only stated the delivery device being a nasal cannula and did not include the oxygen source such as compressed gas or concentrator.
Plan of Correction:	The provider's response(s) for the plan of correction was not received as of 12/14/2019 and will not appear on this violation notice.