VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Golden Care Services, LLC
532 Settlers Landing Road
Hampton, VA 23669
(757) 768-6046

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: Dec. 12, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

Two Licensing Representatives conducted an unannounced monitoring inspection on December 12, 2019 from 6:42 a.m. to 7:54 a.m., and 1:20 p.m. to 4:22 p.m. The following was discussed: organization of records, including address discharged to on discharge notification form of resident, and annual rights and responsibilities of residents review. Please submit your ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it within 10 calendar days. The plan of correction must indicate how the violation will be or has been corrected. The plan of correction must include: 1. Step(s) to correct the noncompliance with the standard(s) 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative measures. If you have any questions, please contact your inspector Alexandra Poulter at 757-613-5133 or alexandra.poulter@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-290-A
Description:	Based on record review and interview, the facility failed to maintain a written work schedule that includes the name and job classifications of all staff working each shift. Evidence: 1. A review of the December 2019 work schedules documented the following: a. On 12-03-19, staff #1 worked the 7 a.m. ? 3 p.m. shift and there were no staff names documented for 3 p.m. ? 11 p.m. or 11 p.m. to 7 a.m. shift. b. On 12-09-19, there were no staff names documented as working on all three shifts. 2. Staff #1 observed and confirmed that the schedules did not have the names and classifications for staff who worked on 12-03-19 and 12-09-19.
Plan of Correction:	Administrator corrected oversight on staff schedule to reflex staffing for time slots left blank. Administrator will review and make sure typos don?t exist. Administrator corrected 12/13/2019.
Standard #:	22VAC40-73-320-A
Description:	Based on record review and interview, the facility failed to ensure within the 30 days preceding admission, a person?s results of a risk assessment documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. Resident #1 admitted on 12-01-19; however, the resident?s tuberculosis screening was not completed until 12-09-19. 2. Staff #1 observed and confirmed resident #1?s tuberculosis screening was not completed within 30 days preceding admission.
Plan of Correction:	Staff contacted physician for initial tb form sent via facility fax. Administrator received corrected and updated form. Administrator corrected on 12/13/2019. Administrator will re confirm dates upon admission going forward.
Standard #:	22VAC40-73-490-A-2
Description:	Based on record review and interview, the facility failed to ensure the licensed health care professional, provided health care oversight at least every three months, or more often if indicated, based on his professional judgment of the seriousness of a resident?s need or stability of a resident?s condition. Evidence: 1. The most current healthcare oversight was dated 04-24-2018. 2. Staff #1 stated the person who conducts the healthcare oversight had been completing them, but is ?holding the paperwork due to a resident not paying a bill.? 3. Staff #1 observed and confirmed the healthcare oversight was not completed every three months and accessible.
Plan of Correction:	A new healthcare oversight manager has been consulted and all resident charts will be reviewed as required. Administrator will be responsible for this. This will be corrected on Feb. 24, 2020. Facility will use alternative HCO manager when routine manager not available.
Standard #:	22VAC40-73-540-B
Description:	Based on record review and interview, the facility failed to ensure that visiting hours were not restricted. Evidence: 1. Resident #1?s Resident Agreement documented visiting hours at the facility are between 9:00 a.m. and 8:00 p.m. daily. 2. Staff #1 observed and confirmed resident #1?s Resident Agreement documented visiting hours and that visiting hours shall not be restricted.
Plan of Correction:	Administrator removed statement from residential agreement and updated it to reflect current standards. Statement was provided to resident and resident family member. Administrator corrected 12/13/2019.
Standard #:	22VAC40-73-610-B
Description:	Based on observation and interview, the facility failed to ensure a menu for snacks for the current week was dated and posted in an area conspicuous to residents. Evidence: 1. The December 2019 menu posted did not document snacks and was not visibly posted anywhere within the facility. 2. Staff #1 confirmed the snacks were not listed on the menu for any week in December 2019.
Plan of Correction:	Administrator created separate calendar for snacks, and it is posted for residents to see. Corrected 12/13/2029. Administrator will create a separate calendar for snacks going forward.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview, the facility failed to ensure medications were administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. During observation of medication administration and review of resident #1?s physician?s orders dated 12-09-19, the following was observed: a. Sertraline HCL 100 mg tablet was changed from ?Take one tablet by mouth every day? to ?Take 1.5 tablet by mouth every day?; however, observed one tablet being administered, b. Donepezil HCL 5 mg tablet was changed from ?Donepezil HCL 5 mg tablet Take one by mouth every day? to ?Donepezil HCL 10 mg tablet Take one by mouth every day?; however, observed one 5 mg tablet being administered, c. Mirtazapine 7.5 mg tablet was changed from ?Mirtazapine 7.5 mg tablet Take one tablet by mouth every day? to ?Mirtazapine 15 mg tablet Take one tablet by mouth every day?, and d. ?Trazodone 50 mg tablet Take one by mouth every day in the evening? was discontinued. 2. The December 2019 Medication Administration Record (MAR) documented resident #1 did not receive the current prescribed dosages of the aforementioned medications on 12-10-19 and 12-11-19. 3. During the medication administration observation on 12-12-19 at 7:42 a.m., resident #1 was administered Donepezil HCL 5 mg by staff #1. Resident #1?s December 2019 Medication Administration Record (MAR) documented resident #1 is to receive Donepezil HCL 5 mg by mouth every day at 8:00 p.m. 4. Staff #1 observed and confirmed that resident #1 had adjusted dosages per the physician?s orders on 12-09-19, and that resident received the former prescribed dosages on the aforementioned dates, and received an evening medication in the morning.
Plan of Correction:	A medication review with resident, primary care physician and medication aide was conducted on 12/13/2019 the medication order was adjusted to reflect resident desire to take medication in the morning. The Medication Aide will give medication as prescribed and a review will happen prior to admission to make sure all persons are onboard with medication regimen for resident. Corrected December 13, 2019.
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview, the facility failed to ensure the interior of the building was maintained in good repair. Evidence: 1. During tour of the facility, the following areas were observed: a. Kitchen floor had brown paint that was chipped, exposing red paint underneath spanning across the length between the kitchen island and table, as well as by the refrigerator. b. Room 4 AB, the carpet was separating in a line spanning approximately three feet. c. Upstairs bathroom, the gray paint was peeling off the wall in several places (next to the sink and behind the toilet and next to the shower). d. Downstairs bedroom, had an oval shaped spackled white spot on the gray painted wall approximately 8 feet in diameter. 2. Staff #1 observed and confirmed the aforementioned areas were not maintained in good repair.
Plan of Correction:	Administrator contacted a maintenance person and made flowing arrangements A. Kitchen floor will be painted on Feb. 22, 2020, B. Bathroom to be painted along with spackled area in bedroom 1AB and 2nd floor bathroom on Feb. 22, 2020.C. Carpet repair scheduled for Feb. 22, 2020. Pictures of all updated repairs will be forwarded to Inspector upon completion.