VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Crossings at Ironbridge
6701 Ironbridge Parkway
Chester, VA 23831
(804) 748-7000

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: April 18, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4-18-23 from 10:30 a.m.- 2:40 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on March 17, 2023 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 66 Number of resident records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting was conducted review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: resident care. A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on a review of resident records the facility failed to ensure that it shall report 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: The record for Resident # 2 (admit date: 2-27-21) contained a hospital discharge summary dated 2-14-23 that noted that the resident was admitted to the hospital due to a fall with a hematoma on 2-12-23. However, the facility did not notify the licensing office of the incident.
Plan of Correction:	Staff will be educated on ensuring they are reporting the reportable incidents to the administrator in a timely manner so that all incidents will be reported in the proper time allotted by the state regulations.
Standard #:	22VAC40-73-430-H-2
Complaint related:	No
Description:	Based on a review of resident records the facility failed to ensure that a copy of the written discharge statement shall be retained in the resident's record. Evidence: The record for Resident # 1 (discharge date: 1-30-23) did not contain a written discharge statement.
Plan of Correction:	Administrator will ensure all discharge statements reflect the initial date that a resident is no longer in the community.
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on a review of resident records the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: The record for Resident # 2 (admit date: 2-27-21) contained an ISP with an expected outcome date of 2-27-23 that was not signed or dated at all.
Plan of Correction:	The administrator will reinforce that the Director of Wellness understands the importance of signing all ISPs once completed and to provide the POA and resident will a copy to look over and have the POA sign the original document in a timely manner before filing in resident's chart.
Standard #:	22VAC40-73-460-E
Complaint related:	Yes
Description:	Based on a review of resident records the facility failed to ensure that any notable change in a resident's condition or functioning, including illness, injury, or altered behavior, and any corresponding action taken shall be documented in the resident's record. Evidence: The record for Resident # 2 (admit date: 2-27-21) contained a hospital discharge summary dated 2-14-23 that noted that the resident was admitted to the hospital due to a fall with a hematoma on 2-12-23. However, there was no documentation in the resident?s charting notes regarding the resident?s fall, injury, hospitalization, and any corresponding action taken. There were no charting notes in the resident?s record after 2-10-23 until 2-15-23.
Plan of Correction:	Staff will be retrained on proper documentation of all falls, change in conditions, and follow up documentation when residents are sent to the hospital.
Standard #:	22VAC40-73-460-H
Complaint related:	Yes
Description:	Based on a review of the facility?s shower logs the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with bathing at least twice a week, but more often if needed or desired. Evidence: There was no documentation in the ?Comments?, ?Initials?, or ?Refusal Reported? sections on the facility?s shower log sheets for Resident # 4- Resident # 8 during the month of December 2022 for the following dates: December 5, 7, 12, 14, 19, 21, 26, and 28.
Plan of Correction:	Staff will be retrained on the proper way to document all refusals of showers and all showers given on the shower log sheet.