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: March 24, 2022 , April 1, 2022 , April 19, 2022 and April 25, 2022

Complaint Related: No

Areas Reviewed:

Part II: Administration and Administrative Services Part IV: Staffing and Supervision Part VI: Resident Care and Related Services Part VIII: Buildings and Grounds Part IX: Emergency Preparedness

Comments:

An unannounced renewal inspection was conducted on 3-24-22 (AR 06:30 a.m./dep 07:45 a.m.). The facility census was 2. Breakfast and medication pass was observed, a tour of the facility was conducted, water temperature was taken, emergency preparedness items observed and reviewed with staff. An exit meeting and Acknowledgement Form was completed with the administrator and sent via email. 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 to the licensing office. If you have any questions, contact the licensing inspector.

Violations:

Standard #:	22VAC40-73-40-B-10
Description:	Based on observation and staff interviewed, the facility failed to ensure that documents required to be posted per the regulation shall be in at least 12-point type or equivalent size, unless otherwise specified. Evidence: 1. On 3-24-22, the menu posted for March 2022 was not in at least 12-point type or equivalent size. 2. Staff #2 acknowledged the menu?s font size was smaller than 12-point type or equivalent size.
Plan of Correction:	The administrator, has printed all postings with bigger font 12 and higher
Standard #:	22VAC40-73-290-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the staff schedule included the job classification of all staff working each shift. Evidence: 1. The staff March 2022 staff scheduled provided to the inspector for review did not include the job classification of all staff working each shift. 2. Staff #1 acknowledged the staff schedule did not include all required information.
Plan of Correction:	Administrator has posted job classifications of staff members on the schedule.
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed the facility failed to ensure the individualized service plan (ISP) included all assessed needs for one of two residents. Evidence: 1. Resident #1?s uniformed assessment instrument (UAI) dated 12-14-21 documented resident is allergic to chocolate. The UAI also documented the resident wanders and is assessed as abusive/aggressive and disruptive. These assessed needs were not documented on the individualized service plan (ISP) dated 5-20-21. 2. Staff #1 acknowledged during the exit meeting the aforementioned resident?s ISP did not include all assessed needs.
Plan of Correction:	Administrator has updated the Individual Service Plan of Resident #1. Administrator has put in place a team of 3 members including case manager to address new and changed needs to be included on an updated Individual Service Plan
Standard #:	22VAC40-73-470-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure, either directly or indirectly, that the health care service needs of residents are met for one of two residents. Evidence: 1. Resident #2?s admitting physical examination dated 9-20-21 documented resident?s need for Physical therapy (PT) and Occupational therapy (OT). The resident?s record did not include documentation of services provided. 2. Staff #1 acknowledged during the exit meeting the aforementioned resident did not receive therapy services.
Plan of Correction:	Administrator has changed the doctors of resident#2 from visiting to local doctors. Administrator is following up with visits and referrals as prescribed by the new doctors
Standard #:	22VAC40-73-640-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure medication was available in a timely manner to avoid missed dosages. Evidence: 1. Resident #2?s March 2022 medication administration record (MAR) documented the following medications were not given and not available for administration: (a) Lorazepam on 3-1-22 through 3-24-22 and (b) Mirtazapine and Olanzapine on 3-5-22, 3-6-22 and 3-7-22 2. Staff #1 acknowledged during the exit meeting the medications for the aforementioned resident were not available for administration.
Plan of Correction:	Administrator had to change the Doctors from Visiting Physicians to local office to avoid any further delay of medication review and prescriptions.
Standard #:	22VAC40-73-650-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure no medication. Dietary supplement, diet, medical procedures, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Evidence: 1. Resident #1?s March 2022 medication administration record (MAR) documented the following medications were discontinued: (a) Venlafaxine 75mg, (b) Benztropine Mesylate and (c) Haloperidol. 2. Staff #1 acknowledged during the exit meeting the medications for the aforementioned resident were documented as discontinued and no discontinued orders were provided to the inspector.
Plan of Correction:	The Med Technician on duty made an appointment with the prescribing Doctor to provide Discontinued orders as referenced for resident #1. Administrator created a form for future appointments for the Doctor to document any changes on a timely manner
Standard #:	22VAC40-73-870-E
Description:	Based on observation and staff interviewed, the facility failed to ensure the furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. Evidence: 1. On 3-24-22 during a tour of the facility with staff #2, the carpet in the bedroom on the first floor was observed to be in need of repair/cleaning, there were white spots in various areas of the carpet. The top right dresser drawer was missing the front portion of the drawer. 2. Staff #2 acknowledged the furniture and carpet in the bedroom were not maintained in good repair.
Plan of Correction:	Administrator has contracted professional Carpet cleaners. Another dresser with full drawers has replaced the broken one.
Standard #:	22VAC40-73-960-B
Description:	Based on observation and staff interviewed, the facility failed to ensure there was a fire and emergency evacuation drawing posted in a conspicuous place on each floor of each building used by residents. The drawing shall show primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes and fire extinguishers, as appropriate. Evidence: 1. On 3-24-22 during a tour of the facility with staff #2, the second story area of the facility did not have a fire and emergency evacuation drawing posted in a conspicuous place of the building used by residents. 2. Staff #2 acknowledged the second floor did not have a fire and emergency evacuation drawing posted in the building.
Plan of Correction:	A Proper fire and emergency evacuation drawing has been posted in a conspicuous place on each floor
Standard #:	22VAC40-73-980-B
Description:	Based on staff interviewed, the facility failed to ensure a motor vehicle that is used to transport residents and used for a field trip, there shall be a first aid kit on the vehicle, located in a designated place that is accessible to staff but not residents that includes all of the required items specified in subsection 980-B of the regulation. Evidence: 1. On 3-24-22 staff was asked to provide the first aid kit for the vehicle used to transport residents. A request was also made for the first aid check list for the vehicle. According to staff #2, there was no first aid kit available on the vehicle. 2. Staff #2 acknowledged there was no first aid kit available on the vehicle used to transport the residents.
Plan of Correction:	Staff#2 put together the First aid kit for the vehicle she was driving. Staff #2 was designated in charge of First Aid Kits of all vehicles transporting residents.