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. 11, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 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:

Type of inspection: Renewal Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 01/11/2023 9:20AM until 2:45PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 16 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication pass, activities throughout being provided during the inspection, noon-time meal An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on staff record review and staff interview, the facility failed to ensure that in a facility licensed for both residential and assisted living care, licensed health care professional staff members shall attend at least 12 hours of annual training. EVIDENCE: The record for staff 2, hired 09/27/2021, contained 7.5 hours of training from the most current training period of 09/27/2021 until 09/26/2022. Interview with staff 5 confirmed this is accurate.
Plan of Correction:	1) PRN licensed health care professionals will have scheduled time to complete annual training through Relias. 2) Staff meeting contained staff training will be mandatory for all employees to include PRN staff 3) DOCS will audit all staff's training records one month before their work anniversary. A communication will be sent out to inform if additional training time is needed. 4) Staff 2 will complete the additional 4.5 hours of required training 5) All componets of this plan will be reported to QAPI by DOCS
Standard #:	22VAC40-73-250-C
Description:	Based on staff record review and staff interview, the facility failed to ensure that all required personal and social data components are included in the staff record. EVIDENCE: The record for staff 2, hired 09/27/2021, did not contain verification that staff 2 had received a copy of her current job description. Interview with staff 5 confirmed this was accurate.
Plan of Correction:	1) Director of Human Resources will ensure that a signed job description is done upon hire and will have a check list with requirements to include signed job description. 2) Director of Compliance will conduct monthly audits on new hires to ensure job description is signed. 3) DOCS will audit ALF new hires to ensure job description is signed 4) Will be reported to QAPI by Director of HR
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to ensure medications were administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: The record for resident 4 contained a physician?s order, dated 09/07/2022, for Humalog insulin 5 units two times daily and hold if blood sugar is less than 90. The December 2022 medication administration record (MAR) for the resident contains documentation that the resident?s blood sugar was 77 at 8:30AM on 12/08/2022; however, the December 2022 MAR contains documentation that the aforementioned insulin was administered to the resident when it should have been held.
Plan of Correction:	1) DOCS and/or designee will offer diabetic training to Webster RMA through staff meetings and Relias 2) Webster Nursing Supervisor will work with Webster RMA during a diabetic med pass once each month during Q1. Education will be provided as appropriate 3) All components of this this will be reported to QAPI by DOCS
Standard #:	22VAC40-73-970-A
Description:	Based on document review and staff interview, the facility failed to ensure fire and emergency evacuation drills conducted in a quarter for each shift were conducted. EVIDENCE: The fire and emergency drills in October 2022, November 2022 and December 2022 were all conducted during day shift. Interview with staff 6 confirmed this was accurate.
Plan of Correction:	1)Each quarter of the year, the facility will conduct fire drills on all three shifts with said fire drills occurring in different months. Fire Drills will be conducted on a varying schedule to incorporate all shifts, including the day shift, defined as 6 am to 2 pm, the evening shift, defined as 2 pm to 10 pm, and the night shift, defined as 10 pm to 6 am. Fire drills will be scheduled one year in advance and will be conducted by a maintenance representative no more than 24 hours in advance of the scheduled day or 24 hours later than the scheduled day. 2)Maintenance staff will be educated on relevant state regulations at the Feb Maintenance staff meeting. Education will be provided by the Risk Manager and Health Services Administrator. 3)The Fire Drill Schedule will be presented to the QAPI committee for approval and will be presented to the QAPI committee monthly for review to ensure compliance with state and federal regulations. 4)The Operations Manager, Compliance Nurse, Director of Clinical Services, and Administrator will be responsible for the continued effectiveness of the mitigation plan.