VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Village at Orchard Ridge
400 Clocktower Ridge Drive
Winchester, VA 22603
(540) 431-2800

Current Inspector: Jill James (540) 418-2631

Inspection Date: Nov. 26, 2019 and Nov. 27, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 63.2 Protection of adults and reporting. 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

Answered questions on/discussed the following topics: 1) Discussed concerns regarding scheduled activities on the weekend and the option to not include a specific time due to needing more flexibility. Reviewed standard 1120.B and explained at least two hours of scheduled activities must be available and 520.I.2.b states the schedule must include the hour of the activity; therefore, not having a specific time would not be an option. 2) Once the generator information is added to the disclosure, ensure a copy is sent to the licensing inspector. 3) Reviewed 830.E regarding resident council, even though there were no recommendations, issues or concerns discussed/noted in the minutes reviewed.. 4) Even though the private sitter agency sends notes by email regarding daily care provided, recommended a notebook be kept in the resident's room for the private sitters to document services provided at the end of each of their shifts.

Comments:

An unannounced monitoring inspection was conducted on 11/26/19 from approximately 8:20 am to 8:15 pm and 11/27/19 from approximately 7:30 am to 1:00 pm. All of the required postings were in place and the facility was clean and free from any foul odors. Upon arrival there were four direct care staff on duty and 18 residents in care. The posted menu and activities calendar accurately reflected this inspector's observations and the one menu substitution was documented. The special diet observed was served according to the physician's order. Medication administration observations were completed for two residents with one registered medication aide. The medication administration records, physicians' orders and medications were reviewed.for both residents. All criminal record checks were reviewed for all current staff hired since the last inspection, as well as one new board officer. Five resident, one discharge, four volunteer, 10 private sitter and four staff records were reviewed. Selected sections of four additional staff and two residents were also reviewed. Individual interviews were conducted with residents, family members and staff. Noncompliance was found in the area of individualized service plans. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based upon documentation, the facility failed to ensure three of the six individualized service plans (ISPs) reviewed included all needs as assessed. Evidence: The ISPs for resident D (completed 8/12/19), E (completed 11/12/19) and F (completed 11/10/19) did not include the specific spheres affected as related to orientation. The ISPs included generic statements that were not specific to the individualized needs of each resident.
Plan of Correction:	1) The Orchard Woods Health Care Center Social Worker reviewed all residents' ISPs and added specific spheres of orientation to all ISPs that were missing the spheres. This documentation was based on the Orientation section indicated on the Uniform Assessment Instrument (UAI) and was individualized for each resident. 2) Upon each new admission, the specific spheres of orientation will be addressed in the ISPs. For current residents, the Orchard Woods Health Center Social Worker will ensure that specific spheres of orientation are addressed in each comprehensive ISPs upon bi-annual review and upon a significant change in a resident's cognition. 3) The Orchard Woods Health Center Social Worker will be responsible for implementing and monitoring spheres of orientation for ISPs.