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. 13, 2022

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.

Technical Assistance:

To ensure a thorough understanding of the standards, the LIs had a discussion with staff regarding standards 210-F and one of the facility's first aid kits.

Comments:

The licensing inspector (LI) for Kendal at Lexington the Webster Center, along with another LI, conducted an unannounced renewal study on 01/13/2022 from 9:06am until 5:07pm, finding 15 residents in care. The inspection included a tour of the physical plant, observation of a medication pass, review of locked medication storage cabinets in multiple residents' rooms, and resident interviews. Six resident records were thoroughly reviewed, and an additional three were partially reviewed in relation to the observation of the medication pass. Sworn disclosure statements and criminal record checks were examined for all newly hired staff, and the records of three staff were thoroughly examined. Additional facility documentation was surveyed for compliance with the Standards for Assisted Living Facilities. Findings were reviewed with facility staff during the inspection. An exit interview was conducted with the Administrator, the Director of Clinical Services, the Nursing Supervisor and the Activities Coordinator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 589-5216.

Violations:

Standard #:	22VAC40-73-1030-B
Description:	Based on staff record review and staff interview, the facility failed to ensure that within four months of the starting date of employment, direct care staff shall attend six hours of training in working with individuals who have a cognitive impairment. EVIDENCE: The record for staff 2, hired 8/16/2021, did not contain documentation of staff 2 receiving six hours of cognitive impairment training within four months of the starting date of employment. Interview with staff 6 concluded that staff 2 did not have cognitive impairment training.
Plan of Correction:	1. Staff #2 is completing 6 hours of cognitive impairment training. 2. An audit of cognitive training for all staff will completed. 3. The Nurse Manager will be tracking staff education and will randomly audit for timely completion of annual reviews. 4. Six hours of Cognitive Training has been added to the New Hire Checklist.
Standard #:	22VAC40-73-210-F
Description:	Based on staff record review, the facility failed to ensure all staff had at least two hours of infection control and prevention training annually. EVIDENCE: The record for staff 1, hired 04/23/2012, contained documentation that staff 1 had only received 0.25 hours of infection control and prevention training for the annual training period of 04/23/2020 through 04/22/2021.
Plan of Correction:	1. Staff #1 will complete 2 hours of Infection Control education. 2. All staff records have been audited to ensure Infection Control education has been assigned. 3. The Nurse Manager will be tracking staff education and complete random audits.
Standard #:	22VAC40-73-250-C
Description:	Based on staff record review, the facility failed to ensure that personal and social data is to be maintained on staff and included in the staff record. EVIDENCE: The records for staff 1, 2 and 3 did not contain a current job description or verification of current certification as a nurse aide and as a registered medication aide.
Plan of Correction:	1. Staff # 1, 2 and 3 have provided copies of their certification. 2. All staff records have been audited to ensure copies of certifications are present in the record. 3. The Nurse Manager will be tracking certifications and completing random audits.
Standard #:	22VAC40-73-250-D
Description:	Based on staff record review, the facility failed to ensure that each staff person required to be evaluated shall annually shall submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. EVIDENCE: The record for staff 3, hired 7/25/2015, did not contain a tuberculosis risk assessment for year 2021.
Plan of Correction:	1. Staff #3 has completed a TB Risk assessment. 2. All staff will complete a TB Risk assessment for CY 2022. 3. The Nurse Manager will be scheduling annual TB Risk Assessments during the same month each year at a staff meeting. 4. TB Assessment will be added to the New Hire checklist to promote completion of the assessment.
Standard #:	22VAC40-73-260-A
Description:	Based on staff record review and staff interview, the facility failed to ensure that each direct care staff member shall receive certification in first aid within 60 days of employment. EVIDENCE: The record for staff 2, hired 8/16/2021, did not contain documentation of first aid certification. Interview with staff 6 confirmed that staff 2 did not have first aid certification.
Plan of Correction:	1. Staff #2 has been scheduled for First Aid Training. 2. An audit of all staff will be completed and arrangements made for First Aid renewals as indicated. 3. First Aid has been added to the New Hire checklist to promote completion within the first 60 days of employment.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure that the physical examination report contained a description of the persons? reactions to known allergies. EVIDENCE: 1. The ?Pre-Admission Physical Assessment? form for resident 1, dated 06/25/2021, indicated that the resident has an allergy to atorvastatin; however, the form did not indicate a description of the resident?s allergic reactions. 2. The ?Pre-Admission Physical Assessment? form for resident 2, dated 06/23/2021, indicated that the resident has allergies to clindamycin, sulfonamides, levoquin and wellbutrin; however, the form did not indicate a description of the resident?s allergic reactions.
Plan of Correction:	1. The Physical Examination Form has been updated. 2. Residents #1 and #2 have had allergy reactions added to their medical record. 3. An audit of all resident records was completed. 4. Allergy Reactions has been added to the IDT quarterly reviews.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review and staff interview, the facility failed to complete the Uniform Assessment Instrument (UAI) as required. EVIDENCE: 1. The individualized service plan (ISP) for resident 2, dated 11/09/2021, stated ?at times I can be socially disruptive and yelling: related to dementia with behaviors?. The private pay UAI for resident 2 indicate that the resident?s behavior pattern is ?appropriate?. Interview with staff revealed that the ISP is correct and the UAI is incorrect as the UAI should indicated that the resident?s behavior pattern is ?abusive/aggressive/destructive?. 2. The UAI for resident 4, dated 1/11/2022, indicated that the resident requires assistance for walking; however, the UAI did not indicate what type of assistance is needed. Interview with staff 6 concluded that resident 4 requires the mechanical assistance of a walker when walking. 3. The UAI for resident 5, dated 8/5/2021, indicated that medication administration is performed by professional nursing staff; however, in addition to professional nursing staff, the facility also employs registered medication aides who administer medications to resident 5. The UAI for resident 5 did not indicate that the resident has been deemed competent to self-administer topical creams and ointments per results of a Self-Administration Assessment completed on 11/22/2021. Finally, the UAI for resident 5 indicated that the resident requires assistance with stairclimbing; however, the type of assistance needed was not indicated. Interview with staff 6 concluded that resident 5 requires the assistance of handrails when stairclimbing. 4. The UAI for resident 6, dated 3/3/2021, indicated that the resident requires the mechanical assistance of shower grab bars and human supervision for bathing; however, the individualized service plan (ISP) for resident 6, dated 3/3/2021, indicated that the resident requires the mechanical assistance of shower grab bars and human physical assistance for bathing. Interview with staff 6 concluded that the UAI was incorrect.
Plan of Correction:	1. Resident #2 has an updated UAI in place. 2. Resident #4 was discharged home with Hospice. She passed on 1/25/22. 3. Resident #5 has an updated UAI in place. 4. Resident #6 has an updated UAI and ISP. 5. All resident UAI/ISPs will be audited for consistency. 6. The IDT will be focusing on matching ISP/UAI with quarterly reviews. 7. The Risk Manager will complete a random audit of 10% of resident records through the rest of CY 2022.
Standard #:	22VAC40-73-550-G
Description:	Based on staff record review, the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually and written acknowledgment of this review shall be placed in the staff person?s record. EVIDENCE: The records for staff 1 and 3 did not contain evidence of an annual resident rights and responsibilities acknowledgment for year 2021.
Plan of Correction:	1. Staff #1 and #3 have completed updated reviews of resident rights. 2. The Social Worker will be completing annual Resident Rights reviews with staff during April each year (when residents are also reviewing their rights.) 3. Resident Rights has been added to the New Hire Checklist.
Standard #:	22VAC40-73-650-B
Description:	Based on resident record review, the facility failed to ensure that physicians or other prescriber orders for administration of all prescription and over-the-counter medications and dietary supplements included the diagnosis, conditions or specific indications for administering each drug. EVIDENCE: 1. The following medications from resident 2?s ?Pre-Admission Physical Assessment?, dated 06/23/2021, did not include the diagnosis, conditions or specific indications for administering the following medications: donepezil 10 mg, fluticasone propion-salmeterol, spironolactone 25 mg, pravastatin 20 mg, potassium chloride 10, losartan-hydrochlorothiazide, citalopram 20 mg, bupropion xl 150 mg, atenolol 25 mg, dorzolamide-timolol, folic acid/multivit-min/lutein, loratadine 10 mg, and cholecalciferol. 2. The following medications from resident 3?s ?Pre-Admission Physical Assessment?, dated 10/15/2021, did not include the diagnosis, conditions or specific indications for administering the following medications: cephalexin 500 mg, omeprazole 20 mg, lactobac 40-bifido, cholecalciferol 10 mcg, aspirin EC 81 mg, trimethoprim-polymyxin, and polyethylene. 3. The physician orders for resident 4, admitted 12/15/2021, did not contain a diagnosis for the following medications: Atorvastatin 20 mg tab, Cetirizine 10 mg tab, Caltrate with Vitamin D3 600 mg (1,500 mg)-800 unit tab, CoQ-10 50 mg capsule, Euthyrox 75 mcg tab, Lumigan 0.01% eye drops, Metoprolol succinate ER 50 mg tab extended release 24 hr, PreserVision AREDS-2 250 mg-90 mg-40 mg-1 mg capsule, Tussin DM 10 mg-100 mg/5 mL oral liquid, Ethacrynic acid 25 mg tab, Xarelto 15 mg tab, Systane 0.4% - 0.3% eye drops, and Vagisil topical powder.
Plan of Correction:	1. Staff have worked with the MD to get supporting diagnosis in place for prescribed medications concerning Resident #2 and #3. Resident #4 has been discharged home with Hospice. 2. The IDT is completing a full audit of all residents to ensure appropriate diagnosis are in place for medications ordered. 3. The IDT has added diagnosis to the ISP checklist for quarterly reviewed to promote continued auditing. 4. The Risk Manger will audit at least 2 medical records per month for the next 3 months.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee. EVIDENCE: The record for staff 5, date of hire 06/07/2021, contained documentation that a criminal history record report was not obtained for staff 5 until 10/25/2021 meaning the criminal history record was not obtained on or prior to the 30th day of employment.
Plan of Correction:	1. Human Resources has implemented a New Hire checklist to include obtaining a criminal history record on or prior to the 30th day of employment. 2. The Risk Manger will be completing random audits of Webster New Hires during CY 2022.
Standard #:	22VAC40-90-40-F
Description:	Based on staff record review, the facility failed to ensure that a criminal history record report issued by the State Police was not accepted by the facility if the report was dated more than 90 days prior to the date of employment. EVIDENCE: The record for staff 2 contained documentation which indicated a hire date of 8/16/2021; however, the criminal history record report in the record for staff 2 was completed on 3/11/2021.
Plan of Correction:	1. Human Resources has implemented a New Hire checklist to include obtaining a criminal history record on or prior to the 30th day employment. 2. The Risk Manger will be completing random audits of Webster New Hires during CY 2022.