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: Aug. 20, 2024

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

Technical Assistance:

22VAC40-73-930 22VAC40-73-1140

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/20/2024 from 8:45 am to 3:08 pm. 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 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed on 3 residents. The following were reviewed: resident and staff records, resident fire and resident emergency drills, and medication carts. Water temperature was measured, and the call bell system was monitored. 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 #:	22VAC40-73-1110-B
Description:	Based on record review, the facility failed to ensure six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee perform a review of the appropriateness of each resident's continued residence in the special care unit. Evidence: 1. Resident #4 has resided in the safe, secure environment since 6/2023; however, there was no review of appropriateness for continued residence in the special care unit in Resident #4?s record.
Plan of Correction:	On 8/28/24 the AL Administrator reviewed all records for residents on the special care unit. All records were complete with a Review of Appropriateness for Continued Residence in a special care unit. Resident #4?s record was updated on 8/21/24. The AL Administrator will audit all Special care Unit residents? records for appropriate every 6 months for accuracy.
Standard #:	22VAC40-73-1120-B
Description:	Based on observation and interview, the facility failed to ensure there be at least 21 hours of scheduled activities available to the residents each week for no less than two hours each day. Evidence: 1. The activity calendar in safe, secure environment does not include two hours of scheduled activities on Saturdays and Sundays.
Plan of Correction:	On 8/28/24 The Activities Director updated the Activity calendar with 21 hours of Activity for all residents on the safe, secure unit. Those hours include two hours of scheduled activities on Saturdays and Sundays. The AL Administrator or designee will audit the calendars quarterly to ensure accuracy.
Standard #:	22VAC40-73-550-G
Description:	Based on record review, the facility failed to annually review the rights and responsibilities of residents with each resident, or their legal representative or responsible individual as stipulated in subsection H of this section. Evidence: 1. The records of Resident #2, Resident #3, and Resident #4 did not include a current written acknowledgement of having been so informed of the review of the rights and responsibilities of residents within the last year.
Plan of Correction:	On 8/28/24 the AL Administrator reviewed all residents? records to ensure an annual review of the Resident?s Rights & Responsibilities was in place. Residents #2, #3 & #4 had a review done and placed in their records. The Clinical Coordinator or appointed designee will audit all records every 6 months for accuracy.
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: Duloxetine 60 mg capsules expired 08/03/2024 for Resident #7 and Westab Max tablets expired 07/14/2024 for Resident #8.
Plan of Correction:	On 8/20/204 all expired medications were disposed of. All medication carts were audited for expired medications by the Clinical Coordinator. Cart audits for expired medications will be completed biweekly by two different shifts to ensure there are no expired medications on any carts. The medication management plan was reviewed with all staff. The cart audits will be reviewed by the Clinical Coordinator or their designee biweekly.
Standard #:	22VAC40-73-650-A
Description:	Based on record review and interview, the facility failed to ensure no medication be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Evidence: 1. Resident #4 is being administered Donepezil 10 mg tablet once daily starting 7/19/2024; however, the facility was unable to provide a valid order from a physician or other prescriber for this change in medication.
Plan of Correction:	On 8/28/24 the AL Administrator & Clinical Coordinator reviewed all monthly Physician Orders for accuracy. Resident #4?s Physicians Orders were reviewed and updated. The Clinical Coordinator will do a monthly Physician Order to Medication Administration Record comparison. The Al Administrator will review quarterly.