VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cave Creek ALF
8088 Lee Highway
Troutville, VA 24175
(540) 992-4599

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: Oct. 15, 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 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

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: 10/15/2024 9:00am until 1:00pm 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: 17 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to ensure that individualized service plans (ISP) were updated when a change in a resident occurred. EVIDENCE: 1. The ISP dated 01/03/2024 in the record for resident 1 has that the resident is on a no concentrated sweet diet. The record has documentation that resident 1 is prescribed a regular diet on a physical examination signed by a physician on 08/28/2024 and documentation of a regular diet in a hospital discharge summary signed by a physician on 10/07/2024.
Plan of Correction:	The ISP was updated with the current diet.
Standard #:	22VAC40-73-640-A
Description:	Based on resident record and facility policy review, the facility failed to implement their medication management plan (MMP) in regard to the filling and refilling of medications to ensure missed dosages. EVIDENCE: 1. The facility MMP has documentation on page 3 that ?The med aide must ensure that all medications and supplements ordered for the residents are filled and refilled in a timely manner to avoid missed doses. The pharmacy sends a thirty-two day supply of medications all at once. The facility receives new supplies of medications every thirty-two days. These medications must be double checked and verified by the med aide staff &/or nurse upon receipt. If new medications are needed or if for some reason there is a discrepancy, the pharmacy is on call 24 hours daily for medications and medication questions. Document up-coming expiration, reorder and refill dates. Contact provider timely to prevent shortage and missed dose of medications?. 2. The October 2024 medication administration record (MAR) for resident 2 has staff initials that are circled as not administering the prescribed medications Docusate Sodium 100mg, Trazodone Hcl 100mg, Divalproex Sod 500mg, Benztropine 0.5mg, Gluco/Chond 500/400mg and Famotidine 20mg daily from 10/01/2024 through 10/15/2024. The back of the MAR has documentation that the medications were not administered as they were not available (Medicaid). The record for resident 2 does not have any documentation that the residents physician was notified of these medications not being available.
Plan of Correction:	The Blueridge social workers and Doctors were notified on several occasions, via phone and email, of the upcoming missing doses. The facility was informed that all services would be withheld until all past and current invoices were paid in full by his insurance company. Resident?s insurance benefits were finally approved. All services have been resumed.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record and medication administration (MAR) review, the facility failed to ensure that all required documentation was include on resident MAR?s. EVIDENCE: 1. The October 2024 MAR for resident 4 does not have staff initials for the administration of the prescribed medication Aspirin 81mg at 11:00am on 10/14/2024. 2. The October 2024 MAR for resident 5 does not have staff initials for the administration of the prescribed medication Benztropine 1mg at 8:00pm on 10/14/2024.
Plan of Correction:	The proper administration of medications was revied by the administrator with staffers
Standard #:	22VAC40-73-925-A
Description:	Based on observations of the facility physical plant, the facility failed to ensure that toilet paper was accessible by each commode. EVIDENCE: 1. The commode in the common bathroom between rooms 3 and 4 did not have toilet paper accessible at 10:02am on the day of inspection.
Plan of Correction:	Ample toilet paper was placed in bathroom