VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Journeys Crossing
102 N. Stuart Avenue
Elkton, VA 22827
(540) 298-0054

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Nov. 23, 2021

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 63.2 General Provisions. 63.2 Protection of adults and reporting. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced renewal inspection was completed by two licensing inspectors on 11/23/2021. The census was 28. A walk through was completed and all required postings were visible. The facility was clean and free from any foul odors. A review was conducted of four resident records and five staff records. The activities calendar and lunch menu were reviewed. An audit of the medication carts was completed. There were four violations during this renewal inspection. Details of non-compliance can be viewed in the violation notice of this report. Upon receipt of this violation notice, a plan of correction is requested for each violation. The plan of correction should include: 1) steps to correct non-compliance of the regulation(s); 2) measures to prevent reoccurrence of non-compliance; 3) person(s) responsible for implementing each step and/or monitoring any preventative measures; 4) the date by which the non-compliance will be corrected. If you have any questions regarding this inspection, please contact the licensing inspector at (540) 292-5932 or rhonda.whitmer@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-250-C
Description:	Based on review of staff records, the facility failed to ensure the record contained all required documentation. EVIDENCE: 1. The record for staff 2, hired 10/04/2021 did not contain a copy of a signed job description. 2. The record for staff 3, hired 05/31/2021 did not contain a sworn disclosure statement. 3. The record for staff 4, hired 07/16/2021 did not contain a signed job description, or an original criminal record report
Plan of Correction:	Facility administrator to ensure that staff records and requirements are completed correctly and within the allotted time after hire. Double check to be completed by RCD for accuracy.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of residents' records, the facility failed to ensure all required components are included on the comprehensive Individualized Service Plan (ISP) EVIDENCE: 1. The UAI for resident 2 indicates resident requires mechanical assistance with dressing. This is not reflected on the ISP. 2. The ISP for resident 4 does not include thick liquids and pureed diet or behavioral interventions.
Plan of Correction:	Facility administrator to ensure Individualized Service Plan (ISP) shows specialized diet and correct ADLs as indicated by the UAI. Monthly checks to be completed and double checked by RCD for completion.
Standard #:	22VAC40-73-640-D
Description:	Based on direct observation and an interview, the facility failed to ensure the drug reference guide for staff who administer medications is no more than 2 years old. EVIDENCE: 1. The drug reference book available to staff who administer medications is dated 2016. 2. The LI interviewed the administrator on 11/23/2021 who confirmed this was the most current drug reference guide available to staff.
Plan of Correction:	Facility administrator to ensure that drug reference manual is up to date and available to staff. Updated drug manual received and place in the nurse?s station and med storage closet.
Standard #:	22VAC40-73-970-A
Description:	Based on review of documents and an interview, the facility failed to ensure fire drills are completed in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51) EVIDENCE: 1. The facility Record of Required Fire and Emergency Evacuation Drills indicates the most recent fire drill was conducted on 08/10/2021 at 9:00am. 2. An interview with the administrator on 11/23/2021 confirmed the last documented fire and evacuation drill was conducted on 08/10/2021 for the day shift at 9:00am.
Plan of Correction:	Facility administrator to ensure Fire and Emergency Evaluation Drills are completed monthly. Monthly schedule to be post in view to maintain accuracy.