VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Carrington Place at Wytheville-Birdmont Center
990 Holston Road
Wytheville, VA 24382
(276) 228-5595

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: July 16, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/16/2024 11:00am to 1:55pm, 08/06/2024 11:34am to 11:44am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/11/2024 regarding allegations in the area(s) of: Resident care and related services and buildings and grounds. Number of residents present at the facility at the beginning of the inspection: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: n/a Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Noon meal Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can be found on the violation notice. 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on a review of resident records, the facility failed to address all identified needs on the comprehensive individualized service plan (ISP). EVIDENCE: 1. The Uniform Assessment Instrument (UAI) for resident #1, completed 12/18/2023, identified the following needs: transferring (mechanical help only), eating/feeding (human help/supervision), bowel (incontinent weekly or more), walking (mechanical help only) and mobility (mechanical help only). These needs were not addressed on the ISP for resident #1, completed 12/18/2023. 2. The UAI for resident #1, completed 12/18/2023, identified the following behavior pattern: wandering (weekly or more), aggressive. Aggressive behaviors were not addressed on the ISP for resident #1, completed 12/18/2023. 3. The UAI for resident #1, completed 12/18/2023, identified the following regarding orientation: disoriented ? all spheres, all of the time, with place and time identified as spheres affected. These needs were not addressed on the ISP for resident #1, completed 12/18/2023.
Plan of Correction:	1. Resident #1 ISP has been updated to reflect current needs as of 08/07/24 2. Resident #1 ISP updated with aggressive behaviors and interventions for staff 3. Resident #1 ISP updated to indicate disorientation all spheres all of the time Completed ISP will be reviewed and signed with Guardian/RP [SIC]
Standard #:	22VAC40-73-930-D
Complaint related:	No
Description:	Based on a review of resident records and interview with staff, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, the following shall be met: 1. This inability shall be included in the resident's individualized service plan (ISP), 2. The ISP shall specify a minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs and 3. 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. EVIDENCE: 1. Resident #1 was admitted to the safe, secure unit on 06/26/2023. 2. Per interview with staff #1, resident #1 would likely know how to use the signaling device in the bathroom but would most likely not know how to use the signaling device in his bedroom, especially if he was not in his bed, i.e. sitting in his recliner. 3. Resident #1?s inability to use the signaling device in his bedroom is not documented on the ISP, completed 12/18/2023. 4. The ISP for resident #1, completed 12/18/2023, does not specify a minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated needs. 5. Per interview with staff #1, direct care staff complete daily rounds at a minimum of every two hours, day and night, but staff are not currently documenting the rounds that are made.
Plan of Correction:	1. Use of signaling device was added to ISP with intervention for Resident #1 2. Rounds will be made and documented at minimum of every 2 hours on all residents that are unable to use signaling device independently 3. New rounding sheet was initiated 08.07.24 for charting every two hour rounds by staff 4. Staff educated on use of rounding sheet and required documentation [SIC]