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: March 18, 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 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 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 03/18/2021 and concluded on 03/23/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 12. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 2 resident records, 2 staff records, staff schedule, recent health care oversight, recent health department inspection, recent fire inspection, dates of the past three fire drills, and the most recent dietitian review submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-270-1
Description:	Based on review of staff records, the facility failed to ensure training at least annually for staff in assisted living facilities that accept, or have in care, residents who are or who may be aggressive. EVIDENCE: 1. The record for staff 1, date of hire 04/23/2012, and staff 2, date of hire 06/19/2019, did not contain documentation that staff 1 had aggressive training for the training year 04/23/2019 through 04/22/2020 or staff 2 for the training year 06/19/2019 through 06/18/2020.
Plan of Correction:	1.) Facility will seek options for training on how to care for aggressive residents. Training to include information, demonstration, and practical experience in self-protection and in the prevention and de-escalation of aggressive behavior - completed by 4/10/21. 2.) Once trainer/training is established, all direct care staff within the Webster Center will complete the mandated training by 5/14/21. 3.) Ongoing - staff will receive training annually (by facility designee on designated date) and at hire (by facility designee as part of new hire training). 4.) All components of this plan will be reported to QAPI.
Standard #:	22VAC40-73-650-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment was started or changed by the facility without a valid order from a physician or other prescriber. EVIDENCE: 1. The record for resident 2 contained documentation for the months of February and March 2021 that staff have been physically assisting resident 2 with ?Dressing TED Hose ? On in the AM and Off in the PM?. 2. The document ?Care Plan?, dated 07/29/2020, for resident 2 showed ?I need physical assistance with dressing as I cannot put on and take off my TEDS without help? and ?Sfaff [sic] provides assistance with TEDS daily and prn while living in the Webster Center through the next review.? 3. The record for resident 2 did not contain a physician?s or other prescriber?s order for TED hose. Interview with staff 3 confirmed that the resident?s record did not contain a physician?s or other prescriber?s order for TED hose for resident 2.
Plan of Correction:	1.) RN obtained signed order for TED hose from NP for resident #2 - completed on 3/22/21. 2.) LPN to complete 100% audit of all current resident orders to ensure that signed physician orders are in place - completed by 4/30/21. 3.) LPN or designee will audit all new orders for 60 days to ensure signed physicians order is in place - completed by 6/30/21. 4.) All components of this plan will be reported to QAPI.
Standard #:	22VAC40-73-680-E
Description:	Based on resident record review, the facility failed to ensure that treatments ordered by a physician or other prescriber were documented and maintained in the resident?s record. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 09/03/2020, for ?Ted hose to both lower legs?. 2. The document ?Care Plan?, dated 05/20/2020, for resident 1 showed that staff are to ?assist with TEDs on every a.m. off every p.m?. 3. Documents, ?POC Daily Charting? did not contain documentation that on 02/04/2021, 02/11/2021 and 03/03/2021 resident 1?s TED hose were taken off by staff in the evening. Also, the document did not contain documentation that on 03/13/2021 resident 1?s TED hose were put on by staff in the morning.
Plan of Correction:	1.) RN and/or designee to complete 100% audit of resident POCs (plan of care documentation) for completion (going back to 2/1/21). Staff will make late entries as appropriate - completed by 4/30/21. 2.) Upon completion of 100% audit staff will audit completion of POCs on a weekly basis. 3.) All components of this plan will be reported to QAPI.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for an employee. EVIDENCE: 1. The record for staff 4, date of hire 10/05/2020, contained documentation that the results of a Criminal Record Check were not obtained until 03/18/2021.
Plan of Correction:	1.) Criminal background check completed on staff #4 on 3/18/21. 2.) HR director and/or designee to complete 100% audit of all Webster Center staffs HR record to ensure proper completion of criminal background check is in place - completed by 4/30/21. 3.) HR director and/or designee to audit completion of criminal background check on all staff hired within the Webster Center for 90 days - completed by 7/30/21. 4.) All components of this plan will be reported to QAPI.