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: Oct. 6, 2020 , Oct. 7, 2020 and Oct. 8, 2020

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 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 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 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS.

Technical Assistance:

Discussed or answered questions on the following: 1) Ensure each blank on the staff orientation form is initialed and dated rather than drawing a line through all except the last blank on each page. 2) Ensure staff J and K complete first aid and cardiopulmonary training within the next month. 3) Recommended a statement be added by the dietician and pharmacy confirming the requirements in the standards were met during their reviews. 4) It is not required to use the individualized service plan model form; however, when using another form ensure it includes all required information (statement regarding staff being awake while on duty, etc.). 5) Upon receipt of the health inspection report, send a copy to this inspector.. 5) Ensure staff B completes the emergency preparedness and resident emergency training by the end of October.

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 renewal inspection was initiated on 10/6/20 and concluded on 10/8/20. The associate administrator was contacted by telephone to initiate the inspection. The associate administrator reported that the current census was 18. The inspector emailed the associate administrator a list of items required to complete the inspection. The inspector reviewed two resident, two volunteer and two staff records. Selected sections of two additional resident and nine staff records were also reviewed. The inspector also reviewed fire drill log sheets, activities calendar, menu, staff schedules, dietary/medication/health care oversights, required postings, resident council meeting minutes, emergency food and water, staff rounds log sheets, and a virtual tour of various areas of the facility was also conducted. Information gathered during the inspection determined non-compliance with administration and documentation of treatment procedures and the violation was documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-680-E
Description:	Based upon documentation, the facility failed to ensure two of the two residents' treatments were administered as well as documented on the treatment administration records (TARs). Evidence: The medication administration record (MAR)/TAR for resident A was blank on 9/19/20 for weight check and Desitin Paste (7:00 am to 7:00 pm); the MAR/TAR for resident B was blank on 9/21/20 and 9/23/20 for the 7:00 pm to 7:00 am shift for documenting all behaviors in the progress notes.
Plan of Correction:	1) Residents were assessed, no adverse reactions noted from not receiving treatments. Doctor was notified, no new orders obtained. Residents' monitored for twenty-four hours to ensure stabilization. 2) An audit was completed immediately on 10/9/2020 by the assisted living program manager (ALPM) to ensure that all residents who were affected did not have any adverse reactions, all issues identified were corrected. 3) The nurse found to be in violation of this practice was educated about the importance of administering treatments and medications to the residents and the five rights of medication administration. The treatment errors and medication policy were reviewed with the nurse. All other nurses and certified medication aides (CMAs) were also educated on the importance of administering treatments and medications to the residents and the five rights of medication administration. Treatment/medication errors and medication policy were reviewed. All team members will be re-educated on the use of and documentation on the electronic MAR/TAR system to ensure understanding and compliance. 4) The ALPM, director of nursing and/or designee will be responsible to ensure compliance. 5) The ALPM or designee will audit 20% of the MARs/TARs. Any actionable trends or patterns will be reported monthly to the Quality Assurance Performance Improvement (QAPI) Committee.