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: Jan. 19, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Recommended an in-service be conducted with all nurses and registered medication aides on administering nasal sprays, eye drops, etc., as well as proper hand hygiene and proper use of the medication cart. Also recommended more frequent medication administration audits be conducted and some be conducted when staff are unaware of being observed.

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/19/2023 from approximately 8:30 am to 1:30 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: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 (selected sections only) Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Medication administration observations, review of medication administration records and physicians? orders. Additional Comments/Discussion: Licensing inspector (LI) reviewed the December and January medication administration records and signed physicians? orders for three residents. LI also observed one nurse and one registered medication aide administer medications. 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. 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 #:	22VAC40-73-100-C-1
Description:	Based upon documentation, the facility failed to implement the facility?s infection control policy regarding hand hygiene. Evidence: 1. On 1/19/2023, the licensing inspector (LI) observed staff 1 at the medication cart on the assisted living unit. A plastic cup with a lid was setting on top of the cart. LI asked staff 1 if that was her personal cup and she stated, ?Yes.? 2. On 1/19/2023, the LI observed staff 1 prepare to pop medications for resident 3. As she started to pop the medication, the LI asked her if she had washed or sanitized her hands and she stated ?No.? The LI asked how often she washed her hands or used hand sanitizer when administering medications and she stated, ?Maybe after every two or three residents.? 3. On page 2, #7, of the facility?s infection control policy it states, ?Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty. b. before and after direct contact with residents; c. Hand washing before preparing and administering each residents medication.?
Plan of Correction:	Staff 1 was immediately educated not to have a personal beverage on the medication cart and to practice hand hygiene between each resident for medication administration passes. Education will be provided to nurses and registered medication aides (RMAs) by director of nursing (DON), registered nurse (RN) Care Coach or designee to follow the infection control practice of not having personal beverages on the medication cart and practicing hand sanitation between medication administration to each resident. Routine, and random medication pass observations to be completed by DON, RN Care Coach or designee.