VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lake Prince Woods
100 Anna Goode Way
Suffolk, VA 23434
(757) 923-5500

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Oct. 5, 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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/05/2023. 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: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 3 residents. The following were reviewed: resident and staff records, medication carts, water temperatures, and the call bell system. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #4 works as direct care staff and does not have a current certification in first aid.
Plan of Correction:	On 10/5/23 the AL Administrator reviewed all employee?s 1st Aid & CPR certifications to ensure each direct care staff members were current and have both components. Staff #4 completed and supplied a copy of her 1st Aid certification on 10/9/23. The HR Director or appointed designee will audit all direct care staff?s certifications monthly and notify the Administrator & staff member if they need recertification.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to review and update individualized service plans as needed for a significant change of a resident?s condition. Evidence: 1. Resident #2 obtained a DNR on 05/09/2023; however, Resident #2?s ISP (dated 05/23/2023) indicates the resident as a full code.
Plan of Correction:	On 10/5/23 the AL Administrator updated resident #2?s UAI & ISP to reflect accurate and current information for a significant change of condition (DNR) obtained 5/9/23. On 10/5/23 the AL Administrator placed a current, updated UAI & ISP onto resident #2?s chart to reflect the code status as a DNR. All UAI?s, ISPs, orders and advanced directives will be audited for accuracy by the AL Administrator or designee.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to ensure their written plan for medication management includes methods to prevent the use of outdated medications. Evidence: 1. The following expired medications were observed in the medication carts at the facility: PRN Acetaminophen 325 mg tablets expired 09/27/2023 for Resident #6, PRN Acetaminophen 500 mg tablets expired 09/30/2023 for Resident #7, and Ondansetron 4 mg tablets expired 08/23/2023 for Resident #8.
Plan of Correction:	On 10/5/23 all expired medications were disposed of. All carts were audited for expired medications by the AL Administrator. The facilities Medication Management Plan was reviewed with all staff. Cart Audits for expired medications will be completed weekly to ensure all expired medications (including OTCs) are removed from the carts. The Cart Audits will be reviewed by the AL Administrator or their designee weekly.
Standard #:	22VAC40-73-660-A-3
Description:	Based on observation, the facility failed to ensure the medication cart be locked and the individual responsible for medication administration shall keep the keys to the storage area on their person. Evidence: 1. At approximately 11:25 am on 10/05/2023, one of the medication carts across from the nursing station in the assisted living was observed to be unlocked and unattended. Later, at 12:55 pm, the medication cart in the living area in the assisted living was observed to be unattended and unlocked with the key in the lock.
Plan of Correction:	On 10/9/23 the AL Administrator in-serviced all direct care staff & Licensed Nurses on proper storage of the keys to the medications carts on their person and ensuring the carts are locked. The AL Administrator or designee will do random audits on all cart, all shifts weekly to ensure staff compliancy.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. A self-reported incident was received on 08/10/2023 regarding a medication error. Resident #4 was given the wrong dose of insulin which resulted in the resident being admitted for observation for 2 days due to hypoglycemia. Staff #1 provided additional information during the onsite inspection and acknowledged the medication error occurred. 2. Resident #1 has an order to be administered an Amlodipine 5 mg tablet once daily and a Losartan 50 mg tablet two times daily with both medications having a parameter to hold if SBP<110 and or Pulse <60. On 10/03/2023, Resident #1?s vitals were documented as 120/58 with a pulse of 61 at 8 am; however, the MAR for Resident #1 indicates the resident was not administered either Amlodipine or Losartan. 3. Resident #2 has an order to be administered an Amlodipine 5 mg tablet and a Lisinopril 40 mg tablet every morning with both medications having a parameter to hold if SBP<110, DBP<60, and or pulse <60. On 10/02/2023, Resident #2?s vitals were documented as 142/75 with a pulse of 57; however, the MAR for Resident #2 indicates the resident was administered both Amlodipine and Lisinopril.
Plan of Correction:	1. On 8/10/23 the AL Administrator reviewed all insulins orders for all residents. All staff were immediately in-serviced on the difference between insulin syringes & pens, correct reading of insulin orders & skills competency completed on insulin. Insulin double verification forms were put onto each resident?s chart to be completed daily. Each insulin dose drawn up will be verified by a qualified medication team member. The AL Administrator or their designee will review the audits daily x 45 days (completed on 9/24/23). Then the AL Administrator or their designee will monitor the audits weekly x 45 days (to be completed 11/8/23). 2. On 10/5/23 the AL Administrator reviewed all residents on blood pressure medications with parameter orders. An audit sheet was completed for each person with the parameters orders on it and is to be completed daily. The staff must document in the resident?s chart if the vital signs are outside of the parameters and what actions were taken. The AL Administrator or their designee will review this audit daily x 4 weeks, then weekly on a monthly basis.