VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Pritchard Road Assisted Living
206 Pritchard Road
Virginia beach, VA 23452
(757) 340-8509

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Oct. 29, 2021 , Nov. 1, 2021 and Nov. 5, 2021

Complaint Related: No

Areas Reviewed:

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 EMERGENCY PREPAREDNESS

Comments:

An initial renewal inspection was initiated on 10-31-21 and concluded on 11-8-21. The administrator in charge was contacted by telephone to initiate the inspection. The administrator reported that the current census was 9. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed two resident records, two staff records, activities calendar, facility menu, staff schedule, health care oversight, pharmacy review, nutritional report, healthcare oversight and fire drills submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 11-5-21. An exit interview was conducted on 11-3-21 and 11-8-21 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 #:	22VAC40-73-210-F
Description:	Based on record review and staff interview, the facility failed to ensure when adults with mental impairments reside in the facility, at least four of the required hours shall focus on topics related to residents? mental impairments. Evidence: 1 Staff #2?s record did not include documentation of four hours of required training in mental impairments. 2. On 11-3-21 and 11-8-21 during exit interviews, staff #2 acknowledged not having documentation of mental health training.
Plan of Correction:	All staff must attend a 4 hour mental training course within a year in order to provide a safe environment for residents.
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed, document reviewed and staff interviewed, the provider failed to ensure it did not retain anyone prescribed a psychotropic medication without a treatment plan for one of two residents. Evidence: 1. Resident #2`s October?s 2021 medication administration record (MAR) documented resident is administered Aripiprazole. The mar documented the medication was prescribed since 6-16-21. The resident?s record did not contain documentation of a psychotropic treatment plan. 2. On 11-3-21 and 11-8-21 during exit interview, staff #2 acknowledged the facility did not have a treatment plan for resident #2?s Aripiprazole (Abilify).
Plan of Correction:	Staff will make sure there's always copy of resident's prescription in the facility and to have documentation of a psychotropic treatment plan in every new order
Standard #:	22VAC40-73-470-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure, either directly or indirectly, that the health care service needs of a resident was met. Evidence: 1. Resident #1?s admission physical examination dated 12-27-20 documented ?physical therapy for strengthening and keeping resident?s balance?. 2. Resident?s individualized service plan did not include documentation of services provided since admission. Staff #2 stated during interview, resident #1 uses a cane when walking outside of the facility. 3. Interview with staff #2 revealed resident #2 did not have physical therapy services. 4. On 11-3-21 and 11-8-21, staff #2 acknowledged resident did not received physical therapy services.
Plan of Correction:	Staff will ensure to follow-up with resident's doctor concerning the physician's referral/order to make sure the resident's needs are being met and to ensure the resident's UAI will agree with the care plan.
Standard #:	22VAC40-73-650-B
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the physician or other prescriber orders, both written and oral, for administration of all prescription and over-the counter medications include the diagnosis, condition, or specific indications for administering the drug. Evidence: 1. Resident #2?s physician?s order dated 6-15-21 for aripiprazole (Abilify) did not include a diagnosis, condition, or specific indications. 2. On 11-8-21 during exit interview, staff #2 acknowledged the physician order did not include the diagnosis.
Plan of Correction:	Staff will follow up with resident's physician when needed to ensure that resident's medication includes specific details concerning resident's diagnosis, condition, and specific indication-for-use.
Standard #:	22VAC40-73-680-K
Description:	Based on record review and staff interview, the facility failed to ensure when medication aides administer the PRN medication, the physician?s order or prescriber?s order shall include the exact time frames the medication is to be given in a 24-hour period, the exact dosage and directions as to what to do if symptoms persist. Evidence: 1. Resident #1?s October 2021 medication administration record (MAR) and physician order dated 4-19-21 documented Furosemide tablet, ?use 2-3 days as needed?. 2. Resident #2?s October 2021 MAR and physician?s order dated 3-9-21 documented Albuterol, ?inhale 1 or 2 puffs?. 3. On 11-3-21 and 11-8-21 during exit, staff acknowledged the PRN medication did not include the exact time frames medication was to be given.
Plan of Correction:	Staff will make sure the resident's physician order for PRN has specific directions that include the exact time frame and exact dosage to give and directions as to what to do if symptoms persist.