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. 9, 2022 and Nov. 10, 2022

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 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:

1. Ensure the model form for fire drills that does not include the corrective action taken column is destroyed and only use the one the facility has updated. 2. On the lift training roster, specify the type of lifts staff were trained on. 3. Ensure residents sign the orientation form even when the legal representative signs it. 4. Rather than leaving not applicable sections of forms blank, recommended putting ?N/A? so it doesn?t give the appearance of being overlooked/missed (social data forms, etc.). 5. On the volunteer orientation form, specify what reporting requirements was reviewed as well as put the title of the volunteer supervisor next to his/her name. 6. Met with the dietician and answered questions and clarified information in the standards. Recommended creating a form that includes all of the information in the dietary review standards and then send it to the licensing inspector for review.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/9/2022 from approximately 8:30 am to 6:20 pm and 11/10/2022 from approximately 7:30 am to 6:30 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 27 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 + selected sections of 2 additional records Number of staff records reviewed: 4+ 1 Volunteer + selected sections of 4 additional records Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 6 + 2 collateral Observations by licensing inspector: Activities, meals, special diets, medication administration, medication carts and postings Additional Comments/Discussion: Met with multiple staff and residents regarding facility procedures, training, resident care, staffing, etc. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-260-C
Description:	Based upon documentation and an interview, the facility failed to ensure the posted list of staff with first aid (FA) and cardiopulmonary resuscitation (CPR) remained up to date. Evidence: 1. On 11/9/2022, the LI observed a posted list of staff with FA and CPR on the secured unit and the assisted living unit and it indicated the list was last ?updated on 07/23/2022.? 2. According to the staff list submitted to the LI on 11/9/2022, there were 13 direct care staff/nurses hired since 7/23/2022, none of which were listed on the posted FA/CPR list. 3. On 11/9/2022, the LI interviewed the care coach who stated the list was not current and did not include the staff hired since 7/23/2022 who had current certification in FA/CPR. .
Plan of Correction:	-Upon notification by the licensing inspector, the first aid and CPR certification list was immediately updated in both care bases by the administrative support clerk. -RN care coach, administrative support clerk, or designee will assure the first aid and CPR certification list is updated upon hire and as team members receive training. -RN care coach, healthcare administrator, or designee will perform routine walking rounds to assure compliance.
Standard #:	22VAC40-73-610-B
Description:	Based upon observations and an interview, the facility failed to ensure the current weekly meal and snack menu was posted. Evidence: 1. On 11/9/2022, the LI observed on the assisted living unit the posted menu which was dated for the week of 10/9 through 10/15. 2. On 11/9/2022, the LI interviewed staff 1 who was the staff in charge of the unit, and she stated she had notified the kitchen staff several times that a current menu was needed; however, it was not received.
Plan of Correction:	-Upon notification by the licensing inspector, a new dining menu was immediately posted by the dining director. -A designated team member from dining will post the updated menu weekly each Saturday evening to reflect the menu for the upcoming week. -RN care coach, dining director, and healthcare administrator will perform routine audits to assure compliance.
Standard #:	22VAC40-73-680-D
Description:	Based upon documentation and interviews, the facility failed to ensure one medication for one of three residents reviewed was administered according to the physician?s order. Evidence: 1. Resident 1 had a signed physician?s order dated 8/23/2022 for ?One 37.5mg tablet Metoprolol Tartrate two times a day for bradycardia hold for SBP<95 DBP<65 or HR<55.? 2. On 10/6/2022, resident 1?s blood pressure (BP) was 96/62; on 10/7/2022 BP was 103/62; on 10/10/2022 BP was 118/64; on 10/15/2022 BP was 98/64; on 10/24/2022 BP was 100/64; on 10/25/2022 BP was 104/64. According to the staff initials on the medication administration record (MAR), the medication was administered on all of the above dates. 3. On 11/9/2022, the licensing inspector (LI) interviewed the care coach who also reviewed the MAR and stated the medication was given in error on the above dates.
Plan of Correction:	-A full audit was performed by the registered nurse (RN) care coach on all assisted living residents currently on blood pressure medications to assure the electronic medical record triggers for a blood pressure to be checked prior to blood pressure medication being administered to a resident to assure it is given withing the correct parameters. -Education will be provided to nurses, and registered medication aides (RMAs) by director of nursing (DON), RN care coach or designee to follow blood pressure parameters as indicated in physician orders to prevent reoccurrence. -Routine, and random medication pass observations will be completed on at least one team member weekly by DON, RN care coach or designee.
Standard #:	22VAC40-73-680-G
Description:	Based upon observations and an interview, the facility failed to ensure two over-the-counter (OTC) medications were labeled with a pharmacy label or the resident?s name. Evidence: 1. On 11/9/2022, the LI conducted a medication cart audit along with staff 1 on the assisted living unit. There was a bottle of Acetaminophen and a bottle of Multi-Carotene and neither bottle of medication had a pharmacy label or the resident?s name on the bottles. 2. On 11/9/2022, the LI interviewed staff 1 who checked both medication bottles and stated the medications should have been labeled with the resident?s name.
Plan of Correction:	-Upon notification by the licensing inspector, a label was placed on the two over the counter medications. -RN care coach will educate team members to assure proper labeling directly upon receipt for over-the-counter medications to prevent reoccurrence. -RN care coach or designee will perform audits upon admission and monthly to assure all medications are labeled appropriately.