VIRGINIA DEPARTMENT OF SOCIAL SERVICES

St. Charles Lwanga House G
2208 Jolly Pond Road
Williamsburg, VA 23188
(757) 345-2388

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Nov. 12, 2021 , Dec. 21, 2021 , Feb. 3, 2022 and Feb. 16, 2022

Complaint Related: Yes

Areas Reviewed:

Part II- Administration and Administrative Services Part II- Personnel Part IV- Staffing and Supervision Part V- Admission, Retention and Discharge of Residents Part VI- Resident Care and Related Services Part IX- Emergency Preparedness

Comments:

An unannounced on-site complaint inspection was conducted on 12-21-21 regarding a complaint received in the office on 10-27-21. Initial reports were received on 11-12-21 from the administrator. Staff was present on 12-21-21 (ar/ 06:45 a.m/dep 09:15 a.m). Administrator not present, inspector went to facility's day support to meet administrator but did not meet. Resident records and other documents and interviews were gathered during the investigation support the allegation, so the complaint is determined to be valid. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy of the plan of correction to the licensing office within 10 calendar days of receipt.

Violations:

Standard #:	22VAC40-73-40-B-8
Complaint related:	No
Description:	Based on observation and staff interviewed, the facility failed to ensure the current license is posted in the facility in a place conspicuous to the residents and the public. Evidence: 1. On 12-21-21 upon entering the facility, the license posted in the facility was not the current issued license. Staff #2 acknowledged, the posted license expired in 2020. 2. On 2-3-22 and 2-16-22 during the exit meeting with staff #1, posting of license was discussed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on interviews, the facility failed to ensure it reported to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. The licensing inspector received a complaint on 10-27-21, informing the office resident #1 went missing from the facility. 2. Collateral interview report received on 11-8-21 documented resident #1 missing from facility. 3. On 11-12-21, interview with staff #1, stated resident #1 was not missing. 4. On 12-21-21, interview with staff #2, resident left the facility and later returned. 5. Staff #2 also stated the resident a situation at the day support program and was no longer in the facility. 6. Resident #2, stated resident bit peer in the forehead at the day support program on 11-5-21 and was removed from the program and the house. 7. On 2-3-22 and 2-16-22, staff #1 acknowledged the incident reports for resident #1?s missing person and resident #1s altercation with injury to resident #2 was not reported to office as licensing as required.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-260-C
Complaint related:	No
Description:	Based on observation and staff interviewed, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR was posted in the facility so that the information is readily available to all staff at all times. Evidence: 1. On 12-21-21 during visit to the facility, staff #2 was asked where the facility?s first aid and CPR posting was located. Staff stated not having a posting of those with first aid or CPR. 2. On 2-3-21 and 2-16-22, staff #1 acknowledged the first aid or CPR listing for staff was not available.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-290-B
Complaint related:	No
Description:	Based on observation and staff interviewed, the facility failed to ensure the posting of the name of the current on-site person in charge was posited in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. On 12-21-21 during a visit to the facility, staff #2 was asked where the facility?s posting of the on-site person in charge was posted. Staff stated being in charge, but there was no posting observed on the day of the inspection. 2. On 2-3-21 and 2-16-22, staff #1 acknowledged the staff person in charge posting was not available.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the facility?s medication management plan was followed for medication administration and documentation on the medication administration record (MAR). Evidence: 1.Resident #1?s November 2021 medication administration record (MAR) documented resident received the following medications at 7:30 a.m. on 11-6-21; 11-7-21 and 11-8-21: (a) Escitalopram (b) Hydroxypam (c) Bupropion, (d) Oxcarbazepine (e) Fluphenazine and (f) Cogentin. MAR also documented resident #1 received the following medication at 5:30 p.m. on 11-5-21, 11-6-21, 11-7-21 and 11-28-21: (a) Flupenazine and Cogentin at 5:30 p.m. on 11-5-21, 11-6-21, and 11-7-21. 2. Staff #1 and #2 stated resident #1 was not in the facility following the incident at the day support program on 11-5-21. Resident #1 last time in the facility was on the morning of 11-5-21. 3. Staff #1 acknowledged, medication was not provided to resident #1 after the morning of 11-5-21.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-960-B
Complaint related:	No
Description:	Based on observation and staff interviewed, the facility failed to ensure the emergency evacuation drawing posted in the facility included all required information. Evidence: 1. The emergency evacuation posting on the wall on the first floor near the kitchen was observed on 12-21-21 to not have the primary and secondary route. 2. The posting was shown to staff #1 who acknowledged the posting did not include all required information.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-960-D
Complaint related:	No
Description:	Based on observation and staff interviewed, the facility failed to ensure the telephone numbers for the fire department, rescue squad or ambulance, police and Poison Control Center shall be posted by each telephone shown on the fire and emergency evacuation plan. Evidence: 1. On 12-21-21 during the complaint inspection, the telephone across from the kitchen, near the bulletin board did not have the telephone number for Poison Control Center posted. 2. Staff #2 acknowledged the Poison Control Center telephone number was not posted. 3. On 2-3-22 and 2-26-22, staff #1 acknowledged the Poison Control Center number was not posted.
Plan of Correction:	Not available online. Contact Inspector for more information.