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 18, 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

Technical Assistance:

To ensure that the facility had a thorough understanding of the standards, the licensing inspectors had a discussion with facility staff during the inspection regarding standard 1150-B.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 04/18/2023 9:20AM until 4:45PM. 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: 48 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: activities, noon-time meal, audit of medication carts 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 #:	22VAC40-73-100-C-2
Description:	Based on observation during an audit of medication carts and policy review, the facility failed to implement its infection control policy regarding blood glucose monitoring practices that are consistent with CDC recommendation. EVIDENCE: 1. Regarding blood glucose staff monitoring, the facility?s infection control policy states, ?Blood glucose monitoring will be obtained using a facility approved and individualized blood glucose monitor and in accordance to manufacturer?s instructions?. 2. At approximately 9:44 AM, one licensing inspector observed two blood glucose monitors within the facility?s memory care unit medication cart. Blood glucose monitor #1 was not labeled with a resident?s name and was inside of a bag labeled with resident 10?s name. Blood glucose monitor #2 was labeled with resident 10?s name and was found inside of a bag labeled with resident 11?s name.
Plan of Correction:	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 4/18/2023 the Director of Nursing immediately obtained two new accu-check machines. The Director of Nursing ensured both storage bags and glucometers were labeled with each resident name. The alleged deficient practice had the potential to affect all residents in the Chaplick Center neighborhood who receive blood sugar monitoring. A 100% physician order audit was completed on 4/20/2023 to review all residents receiving blood sugar monitoring. A medication cart audit was conducted to ensure glucometers and storage bags were labeled and stored accurately. No additional residents were affected. The Chaplick Center manager and/or designee will review all new physician orders for blood sugar monitoring and ensure each resident has an individualized storage bag and glucometer that is appropriately labeled in the medication cart. Nursing team members will be re-educated on the importance of ensuring glucometers and storage bags are labeled and appropriately stored for each resident receiving blood sugar monitoring. The community will ensure compliance through weekly audits x4 weeks then monthly audits x3 months. Progress of audits and new processes will be reported during the quarterly QA meeting. Person responsible for completion: Chaplick Center manager and/or designee by May 15, 2023
Standard #:	22VAC40-73-680-B
Description:	Based on observation during an audit of medication carts, the facility failed to ensure that medications remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. EVIDENCE: 1. At approximately 9:46 AM, one licensing inspector observed a small bottle of Haloperidol injection, USP 5 MG/ML sitting in the top drawer of the memory care medication cart that did not contain a prescription label or a resident?s name.
Plan of Correction:	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 4/18/2023 the bottle of unlabeled Haldol was immediately removed from the medication cart and discarded by the Chaplick Center Memory Care manager. The alleged deficient practice had the potential to affect all residents in the Chaplick Center neighborhood who receive medications administered from the STAT box. A 100% medication cart audit was conducted on 4/18/2023 to ensure all medications had appropriate labeling. No additional medications were identified. No additional residents were affected. The Chaplick Center manager and/or designee will audit the medication carts to ensure all medications are labeled appropriately. Nursing team members will be re-educated on the importance of ensuring medications are labeled with resident?s name and directions for medication use. Nursing team members will be educated to label the medication based upon the physician order if retrieved from the in-house STAT box with the resident name and directions for use. The community will ensure compliance through weekly audits x4 weeks then monthly audits x3 months. Progress of audits and new processes will be reported during the quarterly QA meeting. Person responsible for completion: Chaplick Center manager and/or designee by May 15, 2023
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and staff interview, the facility failed to ensure medications are administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 9 contained a verbal order from the physician on 04/12/2023 to change the resident?s scheduled Novolog to three units before meals and continue with sliding scale insulin and hold if the resident?s blood sugar is less than 150. 2. The April 2023 medication administration record (MAR) reflected this order effective 04/13/2023 for the resident?s scheduled Novolog. 3. The April 2023 MAR indicated that the resident?s blood sugar was 133 on 04/13/2023 at noon and 116 on 04/15/2023 at noon; therefore, Novolog should not have been administered to the resident; however, the MAR includes documentation that Novolog was administered to the resident both dates/times. Also, the April 2023 MAR indicated that the resident?s blood sugar was 121 on 04/14/2023 at 16:30PM; however, the MAR includes documentation that Novolog was administered to the resident. 4. The aforementioned information and documentation was also noted by staff 5 and staff 5 confirmed this was accurate.
Plan of Correction:	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. The insulin order for residents # 9 was verified to be correctly transcribed. The hold parameters were transcribed but were not clearly visible to nursing team members administering medications. The Assisted Living nurse manager updated the order to reflect the hold parameters at the beginning of the instruction section for greater visibility during the medication pass. The attending was notified. Medication error reports were completed with each nursing team member and re-education was provided on the importance of following physician ordered parameters. The alleged deficient practice has the potential to affect other residents residing in the Assisted Living neighborhood who receive insulin with physician ordered parameters. An audit was completed on 4/20/2022 to review compliance with physician orders for insulin management. No additional residents were affected. The Assisted Living manager and/or designee will review all new physician orders to ensure transcription is clear and visible for orders requiring parameter monitoring. Nursing team members will be re-educated on the importance of following physician ordered parameters and transcribing physician ordered parameters at the beginning of the instruction section for greater visibility during medication administration. The community will ensure compliance through weekly audits x4 weeks then monthly audits x3 months. Progress of audits and new processes will be reported during the quarterly QA meeting. Person responsible for completion: Assisted Living manager and/or designee by May 15, 2023
Standard #:	22VAC40-73-680-E
Description:	Based on resident record review and staff interview, the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber are provided according to his instructions and documented and the documentation is to be maintained in the resident?s record. EVIDENCE: 1. The record for resident 5 contained a physician?s order, dated 03/31/2023, for Ted hose to bilateral lower extremities as tolerated by the resident, on in the morning and off at night for edema management. 2. The April 2023 treatment administration record (TAR) for the resident provided during on-site inspection did not contain documentation of whether staff applied the resident?s Ted hose or not during the month of April 2023. This was also noted by staff 5 and staff 5 confirmed that there was no additional documentation.
Plan of Correction:	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 4/18/2023 the Director of Health Services reviewed the TED hose order for resident # 5. It was determined that the order was transcribed correctly. The order type selected was a Treatment FYI which does not provide the means for the nurse to sign that the treatment was refused and/or completed. The Director of Health Services immediately corrected the order on 4/18/2023 to allow for team member documentation. On 4/23/2023 received new orders from in-house attending to discontinue the order for TED hose application. The alleged deficient practice has the potential to affect other residents residing in the Chaplick Center neighborhood who have physician orders for TED hose management. A 100% physician order audit was completed on 4/20/2023 to ensure all orders for TED hose had the correct order type selected to allow team members signature. No additional residents were affected. The Chaplick Center manager and/or designee will review all new physician orders for TED hose to ensure the time code is accurate to allow for a team member signature. Nursing team members will be re-educated on the importance of selecting the correct time code when entering physician orders to ensure a signature block for treatments performed. The community will ensure compliance through weekly audits x4 weeks then monthly audits x3 months. Progress of audits and new processes will be reported during the quarterly QA meeting. Person responsible for completion: Chaplick Center manager and/or designee by May 15, 2023
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the building, the facility failed to store cleaning supplies and other hazardous materials in a locked area. EVIDENCE: 1. At approximately 9:52AM during on-site inspection, one licensing inspector (LI) noted that the door to room G204 (laundry room on second floor) was unlocked. The cabinets located on the wall were also unlocked and contained a bottle of Tide laundry detergent and a spray bottle of Downy wrinkle releaser. This was also noted by staff 1. 2. Also at approximately 10:14AM, one LI noted that the door to room G303 (laundry room on third floor) was unlocked. The cabinets located on the wall were also unlocked and contained the following: two spray bottles of Shout laundry stain remover, a spray bottle of Oxi Clean laundry stain remover, a spray bottle of Dreft laundry stain remover, a spray bottle of Spray & Wash and a bottle of Windex. This was also noted by staff 2. 3. At approximately 10:57 AM, one LI observed a can of New Image hairspray under the bathroom sink of memory care room 148. The can contained a warning to ?Keep out of reach of children?. 4. At approximately 11:01 AM, one LI observed a medication cup that contained an unidentified white cream inside of the cabinet in the bathroom of memory care room 138. 5. At approximately 11:22 AM, one LI observed an oval white pill stamped with ?L612? laying in the hallway outside of room 2201.
Plan of Correction:	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 4/20/2023 new keyless entry locks were placed on the laundry room doors for Assisted Living 2 and Assisted Living 3. Team members were issued a key code to enter the laundry rooms. The alleged deficient practice has the potential to affect other residents residing in the Assisted Living neighborhood. On 4/20/2023 new keyless locks were placed on the laundry room doors for Assisted Living 2 and Assisted Living 3. The Assisted Living manager and/or designee will provide environmental rounds to ensure laundry room doors are locked and secure. Nursing team members will be re-educated on the importance of laundry room doors remaining closed and secured when not in use to prevent accidental injury from chemicals and/or cleaning products. The community will ensure compliance through weekly audits x4 weeks then monthly audits x3 months. Progress of audits and new processes will be reported during the quarterly QA meeting. Person responsible for completion: Assisted Living manager and/or designee by May 15, 2023On 4/18/2023 the can of hairspray was immediately removed from room 148 by the Chaplick Center Memory Care manager. The alleged deficient practice has the potential to affect other residents residing in the Chaplick Center neighborhood. A 100% environmental room audit was completed to ensure all items with specific instructions to ?Keep out of reach of children.? were either removed or placed in a secure, locked cabinet. No additional items were observed. No additional residents were affected. The Chaplick Center manager and/or designee will provide environmental rounds to ensure items containing the label to ?Keep out of reach of children.?, cleaning supplies or other hazardous materials are stored in a secure, locked cabinet. Nursing team members will be re-educated to ensure cleaning items and other hazardous materials are stored in a secure, locked area when not in use to prevent accidental injury from chemicals and/or cleaning products. The community will ensure compliance through weekly audits x4 weeks then monthly audits x3 months. Progress of audits and new processes will be reported during the quarterly QA meeting. Person responsible for completion: Chaplick Center manager and/or designee by May 15, 2023On 4/18/2023 the medication cup containing white cream was immediately removed from room 138 by the Chaplick Center Memory Care manager. The alleged deficient practice has the potential to affect other residents residing in the Chaplick Center neighborhood. A 100% environmental room audit was completed to ensure there were no unidentified treatment modalities left un-attended in resident rooms. No additional residents were affected. The Chaplick Center manager and/or designee will provide environmental rounds to ensure no unidentified treatment modalities are left un-attended in resident rooms to prevent accidental injury from chemicals, cleaning products and/or other items that could be ingested and potentially harmful to the resident. Nursing team members will be re-educated on the importance of not leaving treatment modalities in residents? rooms unattended. The community will ensure compliance through weekly audits x4 weeks then monthly audits x3 months. Progress of audits and new processes will be reported during the quarterly QA meeting. Person responsible for completion: Chaplick Center manager and/or designee by May 15, 2023 On 4/18/2023 the white oval pill observed in the hallway of Assisted Living 2 was immediately discarded by the Assisted Living Licensed Practical nurse.
Standard #:	22VAC40-73-930-D
Description:	Based on resident record review and staff interview, the facility failed to ensure that for each resident with an inability to use the signaling device that once a resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff shall make rounds no less than every two hours, except that rounds may be made on a different frequency if requested by the resident and the facility, and the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds and the documentation shall be retained for two years. EVIDENCE: 1. Residents 2 and 4 reside in the facility?s safe, secure unit. It was verified through an interview with staff 5 that residents 2 and 4 have an inability to use the signing device. 2. Interview with staff 5 revealed that staff do not document the date and time of rounds that have been made and the name of the staff member who made the rounds.
Plan of Correction:	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. The Physician was notified and orders were entered in the electronic medical record on 4/23/2023. The ISP will be updated to reflect every two-hour monitoring of residents residing on the Chaplick Center who have the inability to utilize the signaling call system device. The alleged deficient practice has the potential to affect all residents in the Chaplick Center Memory Care neighborhood. On 4/23/2023 orders were entered in the electronic medical record and the ISP was updated to reflect every two-hour monitoring of residents residing on the Chaplick Center who have the inability to utilize the signaling call system device The Chaplick Center manager and/or designee will ensure all new admissions who have the inability to utilize the signaling call system device for assistance has an order for every two-hour rounding for documentation to monitor emergencies or other anticipated resident needs. Nursing team members will be educated on the importance of documentation for two-hour monitoring for residents residing in a safe, secure neighborhood. The community will ensure compliance through weekly audits x4 weeks then monthly audits x3 months. Progress of audits and new processes will be reported during the quarterly QA meeting. Person responsible for completion: Chaplick Center manager and/or designee by May 15, 2023