VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Glebe
200 The Glebe Boulevard
Daleville, VA 24083
(540) 591-2100

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: April 27, 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:

UAIs were discussed and the components of wheeling and self care with continence were clarified. The use of oxygen was discussed.

Comments:

On 4/27/2022 two inspectors conducted a renewal study )8:30 am to 1:10 pm. 46 residents were in care. Eight resident records, four staff records, and other documents were reviewed. A medication pass was observed and a physical plant tour was done. An exit interview was held on-site the day of the inspection and the facility was given an opportunity to resent additional evidence. A telephone exit interview was done on 4/28/2022.

Violations:

Standard #:	22VAC40-73-660-B
Description:	Based on observations made of the facility physical plant and resident record reviews, the facility failed to ensure that medications kept in resident rooms were stored in an out of sight place in the residents rooms and only for residents who have been assessed as capable of self-administering their own medications. EVIDENCE: 1. During the morning medication pass conducted on 04/27/2022, the LI observed a bottle of Kroger Brand Tussin DM, a container of Preparation H, a bottle of Acetaminophen 325mg tablets and a bottle of Acetaminophen 500mg tablets sitting out on the bookshelf in the room for resident 4. The uniform assessment instrument (UAI) for resident 4, dated 03/27/2022, has documentation that the resident requires medications to be administered by facility staff. There was not a physician?s order for these medications in the record for resident 4. 2. During the morning medication pass conducted on 04/27/2022, the LI observed a container of Bio-Freeze sitting out on the bathroom sink in the room for resident 8. The UAI for resident 8, dated 10/11/2021, has documentation that the resident requires medications to be administered by facility staff. There was not a physician?s order for this medication in the record for resident 8.
Plan of Correction:	This plan of correction is the written allegation of compliance for the deficiencies cited. The submission of this plan of correction is not an admission that a deficiency exists or that one was incorrectly cited. This plan of correction is submitted to meet the requirements established by state regulations. Residents #4 and #8 were involved in the alleged deficient practice. An audit was completed on 4/28/2022 to ensure that there were no over the counter medications observed in residents? apartments. No other residents were affected. On 4/27/2022 the medications were immediately removed from the residents? apartments and the attending was notified regarding the continued use of the over-the-counter medications. Orders were not received from the attending physician to continue the use of the medications. The residents and their families were notified. There were no adverse effects from the alleged deficiency. Team members will be re-educated on the importance of neighborhood rounding and monitoring of the environment to ensure that over-the-counter medications that have not been prescribed by a physician are removed with prompt notification to the attending physician. Re-education with team members will be completed by 5/15/2022. On 4/28/2022 during the Assisted Living/Memory Care Family meeting, families and residents will be re-educated on the importance of notifying the primary nurse when medications are being brought into the neighborhood to ensure that an active physician order is present. The community will ensure compliance through random environmental audits weekly x 4 weeks then monthly x 3 months and report findings during the quarterly QA meeting.
Standard #:	22VAC40-73-860-I
Description:	Based on observations made of the facility physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: 1. The door to the soiled utility room on the AL3 Unit was noted to not lock properly as there was tape and an Oxygen in Use magnet over the latch on the door trim. A bottle of Terro Ant Killer, Proteus Solution, Eco-88 Pet Stain Remover and a can of Heritage Furniture Polish was observed in an unlocked cabinet above the sink. 2. A Micro-Kill One Germicidal wipes was observed sitting out on the counter above a small refrigerator in the facility memory care unit. 3. The door to the food pantry in the facility memory care unit was noted to be propped open on the day of inspection and dietary staff were observed coming and going from this room. A bottle of Clorox Bleach, a container of Micro-Kill One Germicidal wipes, a bottle of Granite Gold Cleaner and several spray bottle containing liquid substances were observed sitting out unlocked in the room.
Plan of Correction:	This plan of correction is the written allegation of compliance for the deficiencies cited. The submission of this plan of correction is not an admission that a deficiency exists or that one was incorrectly cited. This plan of correction is submitted to meet the requirements established by state regulations. On 4/27/2022 the coverings on the door strike plate were removed to allow the door to close properly. The Director of Facilities Services was notified to order and place keyless locks to the Soiled utility rooms and clean linen rooms on Assisted Living 2 and Assisted Living 3. The new keyless entry locks will be installed no later than May 3, 2022. Team members will be issued a key code to enter the soiled utility room for easier access. On 4/27/2022 Director of Environmental Services removed the cleaning products and other products that were identified in the soiled utility room, the Food and Beverage Manager removed the cleaning supplies observed in the Memory Care Pantry and the Memory Care manager removed the Micro-Kill Wipes from the nursing station of the Memory Care neighborhood. Team members will be re-educated on the importance of keeping doors shut and not propping doors open on the neighborhood to prevent accidental injury from chemicals and/or cleaning products that require a secure and locked storage location. Re-education with team members will be completed by 5/15/2022. The community will ensure compliance through random environmental audits weekly x 4 weeks then monthly x 3 months and report findings during the quarterly QA meeting.
Standard #:	22VAC40-73-990-C
Description:	Based on staff interview, the facility failed to hold, at least once every six months, an exercise in which the procedures for resident emergencies are practiced. EVIDENCE: 1. There is no documentation to support that the practice exercises are being done, and this was confirmed by interview with staff 5.
Plan of Correction:	This plan of correction is the written allegation of compliance for the deficiencies cited. The submission of this plan of correction is not an admission that a deficiency exists or that one was incorrectly cited. This plan of correction is submitted to meet the requirements established by state regulations. On 4/28/2022 it was identified that the medical emergency education was not conducted every (6) six months as required by regulatory guidance. Team members will be provided the medical emergency education by 5/15/2022 and every 6 months thereafter to ensure regulatory compliance. The community will ensure compliance in the mandatory education and report findings during the quarterly QA meeting.