VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Gardens of Virginia Beach
5620 Wesleyan Drive
Virginia beach, VA 23455
(757) 499-4800

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Jan. 14, 2021 , Jan. 15, 2021 , Jan. 19, 2021 and Jan. 20, 2021

Complaint Related: Yes

Areas Reviewed:

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

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on January 7, 2021 and concluded on January 20, 2021. A complaint was received by the department regarding allegations in the areas of Resident Care and Related Services as it related to staff performing resident transfers. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Executive Director a list of documentation required to complete the investigation. The evidence gathered could not substantiate the allegation in the complaint; however, non-compliance with standards or law were cited, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. Consultation was provided regarding: Assessment of Serious Cognitive Impairment documentation, Medication Administration Record documentation requirements, Completion of physician?s orders, Staff Training hours, and ISP/UAI updates.

Violations:

Standard #:	22VAC40-73-310-H
Complaint related:	No
Description:	Based on record review and discussion, the facility admitted and/or retained individuals with prohibited conditions. Evidence: 1. Resident #1 was administered Seroquel 25 mag daily without a completed treatment plan. ?Psychopharmacologic Medication Treatment Plan? dated 08-03-2020 did not include the plan of care, behavioral symptoms that indicate use of the psychoactive drug nor prognosis for the Seroquel. 2. Resident #2?s ISP dated 09-10-2020 documented, ?[Resident #2] will receive skilled nursing to treat stage 3 pressure sore...?. 3. Resident #2?s Physician?s Orders/Plan of Care dated 09-25-2020 documented, ?Pt [patient] has an unstageable PU [pressure ulcer] on left heel?? 4. Staff #1 and Staff #2 acknowledged the aforementioned information and could not provide additional documentation for Resident #1 and Resident #2.
Plan of Correction:	Steps to correct the noncompliance with the standard Resident #1 no longer resides in the Community. Resident #2 no longer resides in the Community. Measures to prevent the noncompliance from occurring again The Director of Resident Care and/or designee will be educated by Executive Director and/or designee on the admission and retention of residents as it relates to pressure ulcers, specifically stage III and IV and the admission and retention of resident with orders for psychotropic medications. The Director of Resident Care and/or designee will be educated by Executive Director and/or designee on the components of the ?Psychopharmacologic Medication Treatment Plan?. DRC/designee will meet with home health or hospice to review pressure ulcers weekly to determine stage, treatment and healing. The DRC and/or designee will communicate knowledge of pressure ulcers above a stage II to the Regional Director of Health Services and/or designee prior to admission/readmission for review monthly for three months. Current Residents receiving psychotropic medications will have their ?Psychopharmacologic Medication Treatment Plan? reviewed to ensure the plan includes the plan of care, behavioral symptoms that indicate use of the psychoactive drug and the prognosis for the medication by the DRC and/or designee. New residents with orders for Psychotropic medications will have a ?Psychopharmacologic Medication Treatment Plan? completed prior to moving in to the community. The DRC/designee will audit all new move ins weekly for 4 weeks then 2 time a month for 2 months to ensure all new resident with psychotropic medications have a completed ?Psychopharmacologic Medication Treatment Plan?. Person(s) responsible for implementation of each step and/or monitoring preventative measures The Executive Director is responsible for implementation and monitoring.
Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure the fall risk ratings were reviewed and updated after each fall. Evidence: 1. ?Nurse?s Notes? documented the following falls: a. Resident #2 - 11/06/2020 and 11/20/2020, and b. Resident #3 ? 06/12/2020, 08/20/2020, 09/10/2020, 09/16/2020, and 09/29/2020. The residents? records did not contain fall risk ratings for the documented falls. 2. Staff #1 and Staff #2 acknowledged the records did not contain fall risk ratings for the aforementioned falls. Staff #1 and Staff #2 could not provide fall risk ratings for the aforementioned falls.
Plan of Correction:	Steps to correct the noncompliance with the standard Resident #2 no longer residents in the Community. Resident #3 no longer residents in the Community. The Director of Resident Care and/or designee will conduct a 30 day look back to ensure fall risk ratings were reviewed and updated following a fall. Measures to prevent the noncompliance from occurring again The DRC will be re-educated by Executive Director and/or designee on regulation 22VAC40-73-(5)-325-B including but not limited to completion of a fall risk review after each resident fall. The Director of Resident Care and/or designee will complete a fall risk review following each fall and ensure an update is documented. The DRC will bring documentation to the risk review meeting for verification, weekly for twelve weeks. Person(s) responsible for implementation of each step and/or monitoring preventative measures The Executive Director is responsible for implementation and monitoring.
Standard #:	22VAC40-73-650-E
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure the resident?s record contained the physician?s or other prescriber?s signed written order or a dated notation of the physician?s or other prescriber?s order. Evidence: 1. Resident #1?s Individualized Service Plan (ISP) dated 09-10-2020 documented, ?[Resident #1] will use a hospital bed with half rails for turning and repositioning due to immobility/pain?? 2. Resident #1?s record did not contain a physician?s written order for the half rails on the resident?s bed. 3. Staff #2 could not provide documentation of a physician?s written order for the half rails on Resident #1?s bed.
Plan of Correction:	Steps to correct the noncompliance with the standard Resident #1 no longer resides at the Community. Measures to prevent the noncompliance from occurring again Licensed Clinical staff will be re-educated by the Director of Resident Care and/or designee, on the need for written physician?s orders or dated and notated verbal orders for half rails on a resident?s bed. The DRC and/or designee will conduct random review of orders for half rails monthly for three months. Person(s) responsible for implementation of each step and/or monitoring preventative measures The Executive Director is responsible for implementation and monitoring.
Standard #:	22VAC40-73-660-B
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure a resident may be permitted to keep his own medication in his room if the Uniform Assessment Instrument (UAI) has indicated that the resident is capable of self-administering medication. Evidence: 1. Resident #1?s UAI dated 09-10-2020 documented the resident is dependent in medication administration. 2. ?Skilled Nursing Visit? notes dated 08-20-2020 documented, ?? Moisture barrier cream left at bedside ?? 3. Staff #2 acknowledged Resident #1 was dependent in medication administration, and the barrier cream was left at bedside.
Plan of Correction:	Steps to correct the noncompliance with the standard Resident #1 no longer resides at the Community. Measures to prevent the noncompliance from occurring again DRC/Designee will re-educate current LPNs and CMAs regarding procedures for medications to be left at bedside. The Director of Resident Care and/or designee will educate Hospice teams on the requirements for medications, including creams and ointments to be left at the bedside. The DRC/designee will review current residents on hospice to ensure that any medications, creams or ointments at the bedside have appropriate documentation and storage. Person(s) responsible for implementation of each step and/or monitoring preventative measures The Executive Director is responsible for implementation and monitoring.