VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Westwood Center Assisted Living Facility
20 Westwood Medical Park
Bluefield, VA 24605
(276) 322-5439

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: March 3, 2022

Complaint Related: No

Areas Reviewed:

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

Comments:

Two licensing inspectors conducted an unannounced non-mandated focused monitoring inspection at Westwood Center on 03/03/2022. The inspection started at am and concluded at 10:35 am and concluded at 1:30 pm. The purpose of this inspection was to look at previous violations and determine compliance with standards using the most recent inspection protocol. During the inspection the building was observed, resident and staff files were reviewed, medication carts were observed, physicians orders and medication administration records were reviewed. An exit meeting was held with the director of nursing and other key staff on 03/03/2022 and at that time opportunity was given to find items not available during the inspection. As a result of this inspection 9 violations are being cited. Please develop a plan of correction for each violation cited along with a date of correction and return a signed and dated copy back to the licensing office within 10 calendar days (03/17/2022) of receipt. If you have any questions or concerns please contact your licensing inspector at 276-608-3514. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on observations made during blood sugar checks, the facility failed to follow procedures for infection prevention measures related to job duties, EVIDENCE: 1. Staff # 2 did not put a protective barrier in place while monitoring resident # 1's blood glucose that are consistent with CDC recommendations.
Plan of Correction:	1. Staff #2 was immediately educated on utilizing a protective barrier during blood sugar checks for infection prevention measures related to job duties. Completed 3/2/33. 2. DON/Designee will educate all Med Techs on utilizing a protective barrier during blood sugar checks for infection prevention measures related to job duties. Educations to be completed on or before 3/22/22. 3. DON/designee will monitor use of protective barriers during blood sugar checks for infection prevention measurers related to job duties over the next 6 weeks; randomly thereafter for 2 weeks. [sic]
Standard #:	22VAC40-73-320-A
Description:	Based on documentation review of physical examination reports, the facility failed to ensure the report of such examinations contained all of the required information for one resident in care. EVIDENCE: 1. Resident # 1 was admitted to the facility on 02/28/2022. The physical examination report for resident # 1 dated 02/24/2022 listed Morphine as an allergy but did not include a description of reaction. The Physical examination report also did not include a statement that specifies whether or not resident # 1 is able to self-administer medications.
Plan of Correction:	1. Upon notification, a description of reaction for resident #1 allergy to Morphine was entered on the physical examination form and the specification of whether or not the resident was able to self-administer medication was completed. Completed 3/3/22. 2. An audit was conducted to ensure all residents physical examination form is completed to specify any specific allergic description of applicable and that it is documented whether or not the resident was able to self-administer medication. Audit completed on or before 3/22/22. 3. DON/Designee will educated the attending physician on completing the physical examination form to ensure the report of such examinations contain the allergic reaction if applicable and whether or not the resident was able to self-administer medication. Educations to be completed on or before 3/22/22. 4. DON/Designee will monitor the physical examination for all new admissions to ensure the report contains the allergic reaction if applicable and whether or not the resident was able to self-administer medication is completed over the next 6 weeks; randomly thereafter for 2 weeks. [sic]
Standard #:	22VAC40-73-320-B
Description:	Based on documentation review of subsequent tuberculosis( TB) screenings, the facility failed to ensure a risk assesment for TB shall be completed annually on each resident. EVIDENCE: 1. Resident # 2 was admitted to the facility on 02/17/2022. The last TB assessment for resident # 2 was dated 02/16/2021.
Plan of Correction:	1. Upon notification, Resident #2 TB assessment was completed on 3/3/22. 2. An audit was conducted March 3, 2022 to ensure all residents TB assessments were completed with corrective action if needed. Audit completed on 3/3/2022. 3. DON/designee will educate all RN supervisors that the TB assessments are to be completed annually on each resident. Educations to be completed on or before 3/22/2022. 4. DON/designee will monitor TB assessments to ensure they are completed annually on each resident over the next 6 weeks; randomly thereafter for 2 weeks. [sic]
Standard #:	22VAC40-73-380-A
Description:	Based on documentation review of resident personal and social information the facility failed to obtain the information prior to or at the time of admission. EVIDENCE: 1. Resident # 1 was admitted to the facility on 02/28/2022. Information regarding names of the resident's doctor, dentist, clergyman, armed forces, vocation, hobbies, allergies, DNR, Mental health and substance abuse history and current behaviors were not obtained until 03/03/2022.
Plan of Correction:	1. Upon notification, immediate education was given to the Director of Admissions on the requirement to obtain said personal and social information at or prior to time of admission. 2. An audit was conducted of all residents' personal and social information to ensure documentation was obtained. Completed on or before 3/22/2022. 3. CEO/Designee will educate all Admissions assistants to obtain required personal and social information at or prior to day of admission. To be completed on or before 3/22/2022. 4. CEO/Designee will monitor all admission personal and social information to ensure they are obtained at or prior to the day of admission over the next 6 weeks; randomly thereafter for 2 weeks. [sic]
Standard #:	22VAC40-73-390-A
Description:	Based on documentation review of resident agreements, the facility failed to ensure at or prior to the time of admission, there shall be a written agreement signed by the resident. EVIDENCE: 1. Resident # 1 was admitted to the facility on 02/28/2022. The resident agreement was not signed by resident # 1 until 03/03/2022.
Plan of Correction:	1. Upon notification, immediate education was given tot he Director of Admissions on the requirement to ensure at or prior to time of admission that the written agreement is signed by the resident. 2. An audit was conducted on all residents' written agreements to ensure documentation was obtained. Completed on or before 3/22/2022. 3. CEO/Designee will educate all Admissions assistants of the requirement to ensure at or prior to time of admission that the written agreement is signed by the resident. To be completed on or before 3/22/2022. 4.CEO/Designee will monitor all admission agreements for new admissions are completed prior to or at the time of admission over the next 6 weeks; randomly thereafter for 2 weeks.[sic]
Standard #:	22VAC40-73-410-A
Description:	Based on documentation review of resident orientation, the facility failed to ensure that upon admission the assisted living facility shall provide an orientation for new residents and acknowledgement of receiving the orientation shall be signed and dated by the resident. EVIDENCE: 1. Resident # 1 was admitted to the facility on 02/28/2022. Resident orientation was not provided to the resident until 03/03/2022.
Plan of Correction:	1. Upon notification, immediate education was given to the Director of Admissions on the requirement to ensure that upon admission the assisted living facility shall provide an orientation for new residents and acknowledgement of receiving the orientation shall be signed and dated by the resident/desginee. 2. An audit was conducted of all residents' orientation was completed with acknowledgement of receiving the orientation signed and dated by the resident/designee. Completed on or before 3/22/2022. 3. CED/Designee will educate all Admissions assistants of the requirement to ensure that upon admission to the assisted living facility shall provide an orientation for new residents and acknowledgement of receiving the orientation shall be signed and date by the residents/designee. To be completed on or before 3/22/2022. 4. CED/Designee will monitor new admissions to ensure that upon admission the assisted living facility provided an orientation for the new resident and acknowledgement of receiving the orientation shall be signed and dated by the resident/designee over the next 6 weeks; randomly thereafter for 2 weeks. [sic]
Standard #:	22VAC40-73-470-A
Description:	Based on documentation review of physicians orders, the facility failed to ensure either directly or indirectly that the health care service needs of residents are met. EVIDENCE: 1. Resident # 1 was admitted to the facility on 02/28/2022. The physical exam for resident #1 dated 02/24/2022 ordered physical and occupational therapy for resident #1. On the date of inspection 03/03/2022 no referral had been made for these ordered health care services.
Plan of Correction:	1. Upon notification a referral was made for the ordered health care services for resident #1 for physical and occupational therapy. 2. An audit was conducted to ensure that all residents with to ensure all residents with ordered physical and occupational therapy has a completed referral. Audit completed on or before 3/22/2022. 3. DON/Designee will educate all Med Techs on completing the referral process for physician's orders for physical and occupational therapy. Educations to be completed on or before 3/22/2022. 4. DON/Designee will monitor physician orders for physical and occupational therapy to ensure the referral process is completed over the next 6 weeks; randomly thereafter for 2 weeks. [sic]
Standard #:	22VAC40-73-550-G
Description:	Based on documentation review of resident rights, the facility failed to ensure the rights and responsibilities of resident in Assisted Living shall be reviewed annually with one resident in care. EVIDENCE: 1. Resident #2 was admitted to the facility on 02/17/2020. The last resident rights review for this resident was dated 01/16/2021.
Plan of Correction:	1. Upon notification, immediate education was given to the Director of Social Services on the requirement to ensure the rights and responsibilities of resident in Assisted Living shall be reviewed annually. Resident/designee did review and sign the residents rights and responsibilities on 3/8/2022. 2. An audit was conducted to ensure the rights and responsibilities of resident in Assisted Living have been reviewed annually. Completed on or before 3/22/2022. 3. CED/Designee will educate social worker back up staff of the requirement to ensure the rights and responsibilities of the resident in Assisted Living shall be reviewed annually. To be completed on or before 3/22/2022. 4. CED/Designee will monitor to ensure the rights and responsibilities of resident in Assisted Living is reviewed annually over the next 6 weeks; randomly thereafter for 2 weeks. [sic]
Standard #:	22VAC40-73-650-A
Description:	Based on documentation review of physicians orders, the facility failed to ensure no medication or treatment shall be started, changed or discontinued without a valid order from a physician or other prescriber. EVIDENCE: 1. Resident # 1 was ordered a fleet enema on 2/23/2022. The medication has been stopped but there was no discontinue order in the resident's file. 2. Resident # 1 was prescribed Vitamin D3 5000 IU daily on 02/23/2022. This medication was stopped on 03/01/2022 but there was no discontinue order in resident #1's file. 3. Resident #1 was prescribed Aspirin 81 mg twice daily for Afib on 02/23/2022. According to the medication administration record (MAR) dated 03/01-31/2022resident #1 is only getting this one time a day. There was no order to change the medication in resident #1's record. 4. Resident #1 was prescribed Pepcid 20 mg take twice daily for 28 days on 02/23/2022. According to the MAR dated 03/01-31/2022 resident # 1 is only taking this medication once daily. There was no change order for dosage in resident #1's file.
Plan of Correction:	1. Upon notification, resident #1 discontinue order for the fleet enema was obtained from the attending physician; resident #1 Vitamin D31000 IU daily discontinue order was obtained by the physician; resident #1 Asprin 81mg physician order to change the medication to one time daily was obtained; resident #1 Pepcid 20 mg physician order to change the medication to one time daily was obtained. 2. An audit was conducted of all residents physician orders and the MAR to ensure that there is a physician's order for the medication or treatment to be started, changed or discontinued has valid order from the physician or other prescriber. Audit completed on or before 3/22/2022. 3. DON/designee will educate all Med Techs to ensure no medication or treatment shall be started, changed, or discontinued without a valid order from the physician or other prescriber. Audit completed on or before 3/22/2022. 4. DON/designee will monitor the physician orders with the MAR to ensure no medication or treatment shall be started, changed, or discontinued without a valid order from a physician or other prescriber over the next 6 weeks; randomly thereafter for 2 weeks. [sic]