VIRGINIA DEPARTMENT OF SOCIAL SERVICES

RAH Winthrop Manor
2100 Idlewood Avenue
Richmond, VA 23220
(804) 278-8982

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: April 4, 2022

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Technical Assistance:

Model forms Provided:' - Approval for Placement in Special Care Unit - Assessment for Serious Cognitive Impairment - Review of Appropriateness for Continued Residence in a Special Care Unit - TB Risk Assessment

Comments:

A renewal inspection was conducted on 4/4/2022. Facility staff reported that the current census is 104 residents. The inspector reviewed five (5) resident records, five (5) staff records, required postings, activities calendar, menu, medication administration and observed medication administration, fire and health inspection reports for compliance. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations are documented on the violation notice issued to the facility. An Assessment for Serious Cognitive Impairment is needed for all residents who do not have documentation of a serious cognitive impairment due to a primary psychiatric diagnosis of dementia. The Approval for Placement in Special Care Unit is needed for all residents in the secure unit on the 3rd floor. Please complete and forward to me. An exit interview was conducted with the licensee where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on a review of files of residents living on the facility's safe, secure environment, the residents have not been assessed by an independent clinical psychologist or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia. Evidence: The facility admitted residents to the safe, secure environment on the 3rd floor of the facility in September 2021 as emergency placements. The residents have been assessed by a physician as being unable to recognize danger or protect his or her own safety and welfare, the assessments did not document residents as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia.
Plan of Correction:	As per regulations, all new admissions to the 3rd floor will be examined by an independent physician as having a serious cognitive impairment due to a primary diagnosis of dementia. Since the current residents were accepted on an emergency basis, they will be assessed by a physician. If found to be inappropriately placed, they will be moved.
Standard #:	22VAC40-73-1100-A
Description:	Based on a review of five resident files, written approval was not obtained for two residents prior to placement in the safe secure environment. Evidence: In September 2021 residents # 1 and # 2 were emergency placements to the safe, secure environment on the 3rd floor of the facility. Written approval for placement in the safe, secure environment was not found during a review of the files for residents # 1 and # 2 on 4/4/2022.
Plan of Correction:	The residents admitted to the safe, secure environment will have written approval for placement. Written approval will be secured for all residents on the 3rd floor.
Standard #:	22VAC40-73-1110-B
Description:	Based on a review of five resident files on 4/4/2022, a six month review of appropriateness for continued residence in the safe, secure environment was not performed. Evidence: A six month review of appropriateness for continued residence in the safe, secure environment was not found during a review of the files for residents # 1 and # 2
Plan of Correction:	The administrator will ensure that a six months review of appropriateness for continued residence in the safe, secure environment will be performed.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of individualized service plans for five residents on 4/4/2022, a comprehensive service plan was not completed within 30 days after admission for one resident. Evidence: Resident # 1 was admitted to the facility in September 2022 as an emergency placement. A comprehensive individualized service plan was not found during a review of the resident's file.
Plan of Correction:	Administrator will ensure that the ISPs will be completed per regulations
Standard #:	22VAC40-73-450-F
Description:	Based on a review of individualized service plans for five residents on 4/4/2022, the service plan for one resident was not updated at least once every 12 months. Evidence: Resident # 2 was admitted to the facility in September 2022 as an emergency placement. The resident had an individualized service plan in effect from another VDSS licensed facility dated 11/10/2020. A review of the file for resident # 2 found no documentation to support that the plan was reviewed and updated after admission.
Plan of Correction:	The administrator will ensure that the ISPs will be updated at least every 12 months. ISPs was completed 4/5/22.
Standard #:	22VAC40-73-680-M
Description:	Based on a review of medication administration on 4/4/2022, medications ordered for PRN administration were not available at the facility for one resident. Evidence: During a inspection of medication administration, two PRN medications (acetaminophen and nystatin) for resident # 6 could not be found in the medication cart by staff # 6.
Plan of Correction:	The administrator will ensure that all PRNs are available at the facility as ordered. The two PRNs for the resident was replaced.