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: Sept. 7, 2021 , Sept. 8, 2021 , Sept. 9, 2021 and Sept. 10, 2021

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 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:

1. Carefully review all orders upon receipt and ensure they are signed and contain all information as required within 14 days (oxygen orders must include the source of the oxygen, such as portable tank and/or concentrator). 2. Even though no residents were receiving therapy, ensure this information is included on the individualized service plans (ISPs) and is noted as discontinued when the services stop. Also, now that the pandemic is over, ensure all ISPs (initial, annual and updates) are physically signed by the resident/legal representative. 3. The drug reference book must be replaced prior to 2022. 4. All incidents that may affect the health, safety and welfare of a resident must be reported within 24 hours. This requirement includes stage 2 and above derma ulcers, 911 being called, falls, etc.). 5. The orientation form must be signed by the resident as well as the legal representative; however, not just the legal representative. 6. Staff 3 must complete 10 hours of dementia training prior to 12/16/2021. 7. Recommended creating a checklist for the dietitian to sign and add to the summary. 8. First aid training for staff 2 is due by 9/12/2021.

Comments:

An initial monitoring inspection was initiated on 9/7/2021 and concluded on 9/10/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 18. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed two staff and two resident records, one contract staff, selected sections of five additional resident and two staff records, activities calendar, menu, staff schedules, fire drills, health care oversight, dietary reviews, medication administration records, physicians' orders and other information submitted by the facility to ensure documentation was complete. A virtual tour and inspection was conducted on 9/10/2021. An exit interview was conducted with the administrator on the date of the virtual inspection, 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. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based upon documentation and an interview, the facility failed to report one major incident for one of two residents. EVIDENCE: 1. The progress note on 9/3/2021 at 2:23 pm for resident 1 stated, "Open area/redness on coccyx." 2. The nursing progress note on 9/3/2021 at 4:13 pm stated, "Current open area (stage 2) on resident's right buttock with epithelium tissue." 3. The only report submitted to the licensing office for the stage 2 was received on 9/10/2021. 4. On 9/10/2021, the licensing inspector (LI) interviewed the director of nursing (DON) who stated the stage 2 was not reported within 24 hours.
Plan of Correction:	A seven day incident investigation report was completed by the DON and submitted immediately to the LI. Recent incidents will be reviewed by the DON, administrator, or designee to evaluate if criteria are met for reportable incidents. All team members will be re-educated on an annual basis regarding mandated reporting major incidents to licensing. All team members will be sent the policy regarding mandated reporting major incidents to licensing. All new team members will receive training on reporting major incidents during new staff orientation. The DON, administrator staff educator, or designee will be responsible to ensure compliance. The change in condition assessments will be completed in Point Click Care (PCC) by the licensed practical nurse (LPN) to assist in documentation and requirements for notifications. Any actionable trends or patterns will be reported monthly to the Quality Assurance Performance Improvement (QAPI) Committee.
Standard #:	22VAC40-73-450-C
Description:	Based upon documentation, the facility failed to ensure one of two individualized service plans (ISPs) reviewed was completed with all assessed needs within 30 days of admission. EVIDENCE: 1. Resident 2 was admitted 7/28/2021 and the most current ISP on file was dated as completed and signed on 8/26/2021. 2. The uniform assessment instrument (UAI) dated as completed on 7/14/2021, indicated resident 2 needed mechanical help with toileting, eating, and mobility; however, these needs were not included on the most current ISP. 3. The UAI indicated resident 2 needed assistance with stairs; however, the ISP indicated supervision. 4. The UAI indicated disorientation to place and time; however, this need was not addressed on the ISP. 5. Fall risk rating completed on 7/28/2021 and 9/3/2021 indicated moderate risk; however, this need was not addressed on the ISP. 6. The ISP for resident 2 did not include inability to use the emergency call system and the frequency of rounds required.
Plan of Correction:	The UAIs and ISPs on the residents affected will be corrected by the DON, social worker, LPN, or designee. An audit of completed ISPs for all new admissions within the last six months will be completed. Initial ISPs will be completed with all basic needs and signed within seven days prior to admission. The comprehensive ISP will be updated, completed with all needs and signed for all new residents within 30 days. The DON, social worker, or designee will be responsible to ensure compliance. The social worker and LPN will meet monthly to assure the UAIs and ISPs are aligned and signed. Any actionable trends or patterns will be reported monthly to the QAPI Committee.
Standard #:	22VAC40-73-680-M
Description:	Based on documentation, observations and an interview, the facility failed to ensure one medication for one of two residents was available at the facility. EVIDENCE: 1. Resident 2 had a physician's order signed on 8/6/2021 for morphine sulfate, 0.25ml by mouth every four hours as needed (PRN) for pain. 2. The August and September medication administration records (MARs) listed, "Morphine sulfate (Concentrate) Solution 20MG/ML Give 0.25ml by mouth every 4 hours as needed for pain. Use PRN for pain AEB moaning, grimacing." 3. On 9/10/2021, the LI conducted a virtual audit of the medication cart along with the DON and the morphine sulfate could not be found. 4. On 9/10/2021, the LI interviewed the DON who stated the medication may be in the stat box. 5. On 9/10/2021, the DON checked the stat box and stated the morphine sulfate was not in the stat box.
Plan of Correction:	The DON assured the PRN medication was ordered immediately through the facility pharmacy provider. An audit of all ordered medications will be completed to assure all ordered medications are readily available. Medications will be ordered from the pharmacy upon receiving orders from physician for new medications. Medications will be ordered, or family will be notified, within five days prior to the last dose being administered to ensure no missed doses. The DON, LPN or designee will be responsible to ensure compliance. The DON, LPN, or designee will perform audits monthly. Any actionable trends or patterns will be reported monthly to the QAPI Committee.
Standard #:	22VAC40-73-700-1
Description:	Based on documentation and an interview, the facility failed to ensure four of the four oxygen orders included all required information. EVIDENCE: 1. The signed oxygen orders for residents 2 (signed 9/10/2021), 3 (signed 9/9/2021), 6 (signed 09/10/2021) and 7 (9/10/2021) did not include the source of the oxygen. 2. On 9/10/2021, the LI interviewed the DON who checked the orders and stated they did not include the source of oxygen.
Plan of Correction:	The DON contacted the physicians and the orders were corrected immediately. All residents have been monitored and there are no adverse reactions as a result of this violation. An audit of all oxygen orders was conducted immediately by the DON. All oxygen orders were corrected to include oxygen source - oxygen concentrator or oxygen tank. An ongoing audit will be conducted every week for the next three months. The DON, staff educator, or designee will provide education to nurses and certified medication aides on proper oxygen orders to assure they include oxygen source. The DON, staff educator or designee will ensure compliance with this standard. Any actionable trends or patterns will be reported monthly to the QAPI Committee.