VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Timberview Crossing
351 New Market Road
Timberville, VA 22853
(540) 896-9858

Current Inspector: Jill James (540) 418-2631

Inspection Date: July 21, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A non-mandated complaint inspection was initiated on 07/21/2021 and concluded on 09/14/2021. A complaint incident was received by the department regarding allegations in the areas of resident care and related services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-325-C
Complaint related:	Yes
Description:	Based on document review, the facility failed to document analysis of the circumstances of a fall and interventions that were initiated to prevent or reduce the risk of subsequent falls. EVIDENCE: 1. Facility Resident Incident/Accident reports dated 06/28/2021 indicates resident 1 sustained falls on 06/28/2021 at 9:00am and 5:00pm. 2. There is no documentation of analysis of the circumstances of the falls and interventions that were initiated to prevent or reduce the risk of subsequent falls.
Plan of Correction:	Resident 1 is no longer in the facility. Administrator will assure analysis of fall prevention assessment and interventions are documented and implemented to prevent risk of subsequent falls.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record review, the facility failed to ensure that Individual Service Plans (ISPs) include all required components. EVIDENCE: 1. The ISP for resident 1, dated 05/10/2021 showed the resident is assessed as a high fall risk, but did not include a written description of interventions to prevent or reduce falls. 2. The Uniform Assessment Instrument (UAI) for resident 2, dated 05/10/2021, shows this resident is assessed as needing physical and mechanical assistance with transferring; however mechanical assistance is not addressed on the ISP dated 05/10/2021. 3. The ISP for resident 2, dated 05/10/2021, showed the resident is disoriented to real time, but did not include a written description of the services to be provided to address this need. 4. The ISP for resident 3, dated 06/21/2021, showed the resident is disoriented to time and place, but did not include a written description of the services to be provided to address this need. 5. The ISP for resident 4, dated 06/21/2021, showed the resident is disoriented to time and place, but did not include a written description of the services to be provided to address this need. 6. The ISP for resident 8, dated 08/22/2020, showed the resident is disoriented to time and place, but did not include a written description of the services to be provided to address this need. 7. The UAI for resident 9, dated 02/26/2021, shows this resident as assessed as wandering weekly or more, however the ISP indicates resident does not wander. 8. The ISP for resident 10, (not dated), showed the resident is disoriented some spheres all of the time, but did not include a written description of the services to be provided to address this need. 9. The UAI for resident 10, dated 06/26/2021 shows this resident as assessed as needing assistance with meals and spoon fed, however this is not addressed on the ISP. 10. The ISP for resident 12, dated 09/16/2020, showed the resident is disoriented to place, person, and time but did not include a written description of the services to be provided to address this need. 11. The UAI for resident 12, dated 09/12/2020 showed the resident as assessed as having wandering behavior, however the ISP indicates resident does not have wandering behavior. 12. The UAI for resident 13, dated 12/15/2020 showed the resident as assessed as requiring professional nursing staff to administer medications; however the ISP indicates medication is to be administered by a Registered Medication Aide (RMA).
Plan of Correction:	All resident Individualized Service Plans (ISPs) will be audited to ensure all required components are included. The administrator will review all ISPs for all new admissions and there after, monthly to ensure accuracy and completeness.
Standard #:	22VAC40-73-450-D
Complaint related:	No
Description:	Based on record review, the facility failed to ensure the Individualized Service Plan (ISP) included services provided by hospice. EVIDENCE: 1. The hospice plan of care for resident 1 effective 07/06/2021 indicated resident receives skilled nursing twice weekly and medical social worker visits once a month, however this is not indicated on the Individualized Service Plan. 2. The hospice plan of care for resident 13 effective 07/01/2021 indicated resident receives skilled nursing and hospice aide services twice weekly and medical social worker visits once a month, however this is not indicated on the Individualized Service Plan.
Plan of Correction:	All resident Individualized Service Plans (ISPs) will be audited to ensure all services provided by hospice are included. The administrator will review all ISPs for all new admissions and there after, monthly to ensure accuracy and completeness.
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on record review, the facility failed to ensure the Individualized Service Plans (ISPs) are signed and dated by the administrator and by the resident or his legal representative. EVIDENCE: 1. The Individualized Service Plan for resident 1, dated 05/10/2021 does not include the signature of the resident or legal representative. 2. The Individualized Service Plan for resident 2, dated 05/10/2021 does not include the signature of the resident or legal representative. 3. The Individualized Service Plan for resident 3, dated 06/21/2021 does not include the signature of the resident or legal representative. 4. The Individualized Service Plan for resident 4, dated 06/21/2021 does not include the signature of the resident or legal representative. 5. The Individualized Service Plan for resident 5, dated 06/21/2021 does not include the signature of the resident or legal representative. 6. The Individualized Service Plan for resident 7, dated 05/12/2021 does not include the signature of the resident or legal representative. 7. The Individualized Service Plan for resident 9, dated 02/21/2021 does not include the signature of the resident or legal representative. 8. The Individualized Service Plan for resident 10, is not dated by the administrator and does not include the signature of the resident or legal representative.
Plan of Correction:	All resident Individualized Service Plans (ISPs) will be audited to ensure the required signature and date are included per requirements. The administrator will review all ISPs for all new admissions and there after, monthly to ensure accuracy and completeness.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on record review, the facility failed to ensure the Individualized Service Plan (ISP) is reviewed and updated annually. EVIDENCE: 1. The most recent ISP for resident 6 is dated 08/26/2019.
Plan of Correction:	All resident Individualized Service Plans (ISPs) will be audited to ensure all are updated annually or as needed for a significant change in the resident's condition. The administrator will review all ISPs for all new admissions and there after, monthly to ensure accuracy and completeness.
Standard #:	22VAC40-73-450-G
Complaint related:	No
Description:	Based on record review, the facility failed to ensure a current copy of the Individualized Service Plan (ISP) is provided to the resident. EVIDENCE: 1. The section on the ISP for resident 2 dated 05/10/2021 indicating if resident has received a copy of the ISP is not completed. 2. The section on the ISP for resident 8 dated 08/22/2020 indicating if resident has received a copy of the ISP is not completed.
Plan of Correction:	All resident Individualized Service Plans (ISPs) will be audited to ensure acknowledgment of receipt by the resident. The administrator will review all ISPs for all new admissions and there after, monthly to ensure accuracy and completeness.
Standard #:	22VAC40-73-470-F
Complaint related:	Yes
Description:	Based on document review, the facility failed to secure immediate medical attention from a licensed health care professional when a resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred. EVIDENCE: 1. The facility Resident Incident/Accident Report dated 06/21/2021 at 7:00pm for resident 1 indicates "staff saw resident starting to stumble and lean back. Staff tried running to catch resident. Resident reached out his arm to staff. Staff grabbed his hand but he still fell backwards. Staff noticed knees were scraped. Resident admitted he fell earlier and didn't say anything." 2. The facility Resident Incident/Accident Report dated 06/21/2021 at 7:00pm for resident 1 indicates resident had scraped knees and blood pressure reading of 186/78. 3. The facility chart note indicates the administrator was notified at 7:30pm. 4. There is no documentation resident was seen by a licensed health care professional after having two falls and a systolic blood pressure of 186.
Plan of Correction:	Administrator will assure when a resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect such as occurred, medical attention from a licensed healthcare professional will be secured immediately. The administrator will ensure incidents are filed timely and when there is fall frequency or elevated blood pressure, medical attention will be secured immediately. Resident 1 is no longer in the facility.
Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on record review, the facility failed to implement a written plan for medication management to ensure that residents do not receive medications or dietary supplements to which they have known allergies. EVIDENCE: 1. The July 2021 Medication Administration Record for resident 12 indicates resident has an allergy to Acetaminophen. 2. The physical exam for resident 12 dated 09/21/2016 indicates resident has an allergy to Acetaminophen. 3. Resident 12 has a physician's order effective 06/30/2020 for PRN Acetaminophen. 4. The facility medication management plan dated 02/01/2018 indicates on page 4 #9a and page 5 #10a "when a medication aide receives a new order or change in order, that there are no known allergies to medication/nutritional supplement, fax order to facility pharmacy to be put in eMar, fax to supplying pharmacy and put order in merge folder." 5. The facility medication management plan page 10 #29 indicates "The medication management plan, policy and procedure will be reviewed yearly by the administrator to assure accuracy." 6. There is no documentation indicating the facility medication management plan has been reviewed since 02/01/2018.
Plan of Correction:	The administrator will ensure the medication management plan is followed regarding new orders and a change in orders. The plan will be reviewed with all staff who administer medications and documented in the staff file. The administrator will ensure all new staff who are qualified to administer medications are oriented to the facility's medication management plan. Resident 12 is no longer in the facility.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on record review, the facility failed to administer medications in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Resident 1 has the following order: C/DOPA-L/DOPA 25-100 TB-Take one tablet by mouth four times a day for Parkinson's. 2. The Medication Administration Record (MAR) for resident 1 indicates medication was not administered on 06/03/21 at 5:00pm "order needing clarification"; 06/03/21 at 8:00pm "medication not available"; 06/05/21 at 8:00pm "order needing clarification"; 06/06/21 at 5:00pm "order needing clarification"; 06/6/21 at 8:00pm "order needing clarification; 06/07/21 at 7:00am "order needing clarification"; 06/07/21 at 11:00am "order needing clarification"; 06/21/21 at 8:00pm "medication not available" 3. Resident 1 has the following order: Hydrazaline 10mg tablet-Take one tablet by mouth every day as needed to systolic blood pressure greater than 180. The facility Resident Incident/Accident Report dated 06/21/2021 at 7:00pm for resident 1 indicates resident had scraped knees and blood pressure reading of 186/78. There is no documentation of Hydrazaline being administered on 06/21/2021.
Plan of Correction:	The administrator will have a licensed health care professional complete a medication administration observation on each staff who are qualified to administer medications and going forward, this will be completed quarterly. The administrator or licensed health care professional will review the Medication Administration Records (MARs) weekly for the first month and thereafter, monthly.