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: Dec. 15, 2023

Complaint Related: No

Areas Reviewed:

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSING PROCESS

Comments:

Type of inspection: Renewal An unannounced mandated renewal inspection conducted on 10-16-23; AR (07:20 a.m./Dep 10:00 a.m.) Census was 6. Administrator was not present during inspection. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A final exit meeting will be conducted. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on staff interviewed, the facility failed to insure 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. On 10-16-23 during the check of the facility?s first aide kit with staff #2, staff stated the facility did not have power for approximately a day or two. According to staff this occurred around the Columbus Day timeframe, did not remember exact time. The staff stated the residents were relocated to a facility operated by the agency. 2. On 10-16-23, staff #2 acknowledged the facility was without power and the residents were transported to the facility operated by the agency on or about September 23, 2023.3. 3. According to staff #1, the facility?s generator did not work. 4. Staff #1, on 12-13-.23 acknowledged not reporting this incident to the department.
Plan of Correction:	Administrator has conducted the generator company for needed repairs
Standard #:	22VAC40-73-640-D
Description:	Based on observation and staff interviewed, the facility failed to ensure it had readily accessible at least one pharmacy reference book, drug guide, or medication handbook for nurses that is no more than two years old as reference materials for staff who administer medications. Evidence: 1. On 10-16-23 during the medication pass observation with staff #2, the facility did not have at least one pharmacy reference book, drug guide, or medication handbook that was no more than two years old as a reference material for staff who administered medications. 2. Staff #2 acknowledged that facility did not have a medication handbook, reference guide or drug book that was least than two years old.
Plan of Correction:	Administrator retrieved a current pharmacy reference book
Standard #:	22VAC40-73-680-I
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the medication administration record included all required information for four of six records. Evidence: 1. On 10-16-23, during the medication pass observation with staff #2, resident #1?s October 2023 medication administration record (MAR) did not include the diagnosis, condition, or specific indications for administering the drug or supplement for Remeron (Mirtazapine), Zyprexa (Olanzapine) and Risperidone (Risperdal). 2. Resident #2?s October 2023 MAR did not have diagnosis for Benztropine, Invega Sustane, Lithium Carbonate, Olanzapine (Zyprexa), Paliperidone, Trazodone and Venlafaxine (Effexor XR). 3. Resident #4?s October 2023 MAR did not have diagnosis for Buspirone, Invega Sustane, Risperdal (Risperidone), Trazodone, Benztropine, Lexapro (Escitalopram) and Tenormin (Atenolol). 4. Resident #6?s October 2023 MAR did not have diagnosis for Remeron (Mirtazapine). 5. On 10-16-23 #2 acknowledged the aforementioned residents? October 2023 MAR did not include the diagnosis for medications prescribed. 6. On 12-13-23, staff #1 acknowledged the residents? October MAR did not include the diagnosis for medications prescribed for the aforementioned residents.
Plan of Correction:	Administrator has designated an additional Med-Tech staff who would continuously ensure that the MAR has all diagnosis as indicated on the physician orders and treatment plans