VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Kendal at Lexington Webster Center
160 Kendal Drive
Lexington, VA 24450
(540) 463-1910

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: Jan. 9, 2020

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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 SANCTIONS.

Comments:

The LI for Kendal at Lexington Webster Center conducted an unannounced renewal study at the facility on 1/9/2020 from 10am until 2:30pm in conjunctions with two other LI's and noted 14 residents to be in care. Resident and staff records as well as other forms of facility documentation were reviewed and interviews were conducted with residents and staff. A tour of the facility physical plant was conducted and the morning medication pass was observed. To provide better understanding of the regulations, the LI discussed the following regulations with the facility administrator: 40-73-250-A- all employees working/providing services within the facility must have a completed staff records to include all training requirements. 40-73-250-D and 320-B- policies and procedures and Physician oversight for facility RN's that screen or administer PPD's for Tuberculosis screenings. 40-73-680-M The use of standing orders, proper labeling of PRN medications and the use of stat boxes for routine PRN orders. 40-73-970-E- all required information on fire drill logs. Please respond back to your LI with a plan of correction within 10 days of receipt of this notice. If you have any questions please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-360-A
Description:	Based on a review of resident records, the facility failed to obtain documentation of an emergency placement from a adult protective services worker or an independent physician for private pay individuals. EVIDENCE: 1. The records for resident 1, admitted on 11/14/19 and resident 2 admitted on 11/22/19 had admission paper that was out side of the required time frames for admission. Interviews with staff express that these residents were admitted as emergency placements. The records for these residents did not contain documentation of being an emergency placement from an adult protective services worker or an independent physician.
Plan of Correction:	1. Regarding resident affected: Late physicians? orders were obtained to document the necessity for emergency admissions for residents #?s 1 and 2. 1/31/20 2. Regarding residents potentially affected: LPN Supervisor/designee will audit to identify any other emergency admissions completed in the past 60 days. If the required documentation for an emergency admission is not present, staff will obtain a late physicians? order to document the necessity for the emergency admissions. 1/31/20 3. Systematic changes: Staff reeducated by DSS Inspector at the time of ALF survey on requirements for emergency admission. 1/9/20 Admission paperwork updated to include a section for emergency admissions to ensure necessary documentation is obtained for emergency admissions.1/17/20 4. Monitoring: LPN Supervisor/designee will audit all emergency admissions for next 60 days to ensure required documentation obtained. Results will be reported to QAPI. 2/1/20 5. All components of this plan will be completed by February 28, 2020, with ongoing monitoring, which will be reported to QAPI.
Standard #:	22VAC40-73-660-B
Description:	Based on observations made of the facility physical plant, the facility failed to ensure that medications in resident rooms were stored in an out of sight place. EVIDENCE: 1. The room for resident, room 211, was noted to have a bottle of Hydrogen Peroxide sitting out on the bed side table. The record for resident 7 did not contain an order for Hydrogen Peroxide and interview with staff expressed that the facility administers medications to resident 7.
Plan of Correction:	1. Regarding resident affected: Hydrogen Peroxide removed from resident #7?s apartment by Registered Medical Aide. 1/9/20 Resident reeducated by LPN Supervisor that any medications are stored out of sight and must have a current physician?s order. 1/9/20 2. Regarding residents potentially affected: No other residents were identified as being affected; however, staff complete regular rounds to help ensure compliance and address any issues. Ongoing 3. Systematic changes: In-room medications will be added to the agenda for the monthly Resident Council Meeting. Residents will be reeducated that they must have a current physician?s order for medications and the items must be stored out of site. Need date Administrator will send a memo to residents and their responsible parties reminding of the regulations for in-room medications. 1/31/20 4. Monitoring: LPN Supervisor/designee will ensure that rounds are made weekly, Monday-Friday, to ensure compliance and address any issues. Results will be reported to QAPI. On going 5. All components of this plan will be completed by February 28, 2020, with ongoing monitoring, which will be reported to QAPI.
Standard #:	22VAC40-73-680-M
Description:	Based on observations of the facility first aid kit, the facility failed to ensure that PRN medications were properly labeled for specific residents. EVIDENCE: 1. The first aid kit located in the nurses station and in the facility transportation vehicle contained a bottle of Glucose tablets that were labeled from the pharmacy for Kendal Webster Center First Aid Kit and did not contain a specific resident name.
Plan of Correction:	1. Regarding resident affected: Glucose tabs immediately removed from the First Aid kits by LPN Supervisor. 1/9/20 2. Regarding residents potentially affected: No residents were affected. 1/9/20 3. Systematic changes: Administration reeducated by DSS inspector that any PRN medications must be properly labeled for specific residents. 1/9/20 LPN and/or RN Supervisor will reeducated Webster staff that any PRN medications must be properly labeled for specific residents. 2/15/20 4. Monitoring: LPN Supervisor/designee will review first aid kits at least monthly x 60 days to ensure that only items required in the first aid kit are present. If any additional supplies are included, LPN Supervisor will remove the item and ensure it is properly labeled for individual resident use. Results will be reported to QAPI. 2/1/20 5. All components of this plan will be completed by February 28, 2020, with ongoing monitoring, which will be reported to QAPI.
Standard #:	22VAC40-73-980-H
Description:	Based on tour of the physical plant and staff interviews, the facility failed to ensure there was at least 48 hours of water supply on site. EVIDENCE: 1. On the day of inspection the facility census was 14. Staff person 2 indicated that there were 18 gallons of water on site. The Virginia Department of Emergency Management recommends one gallon of water per pay for each resident and staff member which would require at least 28 gallons of water on site on the day of inspection to have a 48 hour supply.
Plan of Correction:	1. Regarding resident affected: Dining Supervisor ensured at least 48 hours of water supply was on site by 1/10/20. 2. Regarding residents potentially affected: Dining Supervisor ensured at least 48 hours of water supply was on site by 1/10/20. 3. Systematic changes: Culinary staff reeducated that water must be replaced as it is used or as it expires to ensure availability of emergency water. 1/21/20 240 gallons of water onsite, stored separately, with expiration date of early 2022. Water will be replaced by December 2021 to ensure availability of emergency water. 1/21/20 4. Monitoring: Director of Culinary will audit water supply at least monthly x 60 days. 2/1/20 Director of Culinary will ensure that as water is utilized, or expires, it has been replaced to ensure emergency availability of water. 2/1/20 5. All components of this plan will be completed by February 28, 2020, with ongoing monitoring, which will be reported to QAPI.