VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Manorhouse Assisted Living & Memory Care
13500 North Gayton Road
Richmond, VA 23233
(804) 360-7777

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: Nov. 10, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 11-10-2022, 10:30 a.m. ? 11:40 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on September 29, 2022 regarding allegations in the area of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 89 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 Alexandra Poulter, Licensing Inspector at (804) 662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-220-A
Description:	Based on record review and interview with staff, the facility failed to ensure before private duty personnel services are initiated, the facility obtained in writing the information on the type and frequency of the services to be delivered to the resident by the private duty personnel, as well as provide orientation and training to private duty personnel regarding the facility?s policies and procedures. Evidence: 1. Resident #1 admitted 7-25-2022 to the facility. The documentation provided regarding Resident #1?s Private Duty Personnel (PDP) services did not include documentation of the type and frequencies of services, nor did the resident?s record contain the orientation and training undergone by PDP staff. 2. Staff #1 confirmed the absence of this required documentation for the PDP during exit.
Plan of Correction:	Develop a plan to ensure orientation of private duty sitter and ensuring that community receives in writing the type and frequency of the services to be delivered to the resident. 1) Review UAI and ISP of current resident with private duty staff, care plan review 2) Signature of private duty staff understanding what is required to care for the resident 3) Documentation reflecting orientation and training regarding building protocols with signature training received.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview with staff, the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs based upon the assessment of psychosocial, behavioral, and emotional functioning, and other sources. Evidence: 1. Resident #1 admitted 7-25-2022. Resident #1?s current and only ISP in the record (undated) did not address exit-seeking behaviors as seen in the Nurse?s Notes as well as Physician?s Progress notes. The Nurse?s Notes and Progress Notes documented: a. Nurse?s Notes - 8-01-2022 7 a.m. ? 3 p.m. shift: ?? advise 24 hr sitter with exit seeking [POA] aware. b. Progress Notes ? 8-05-2022: ?[Resident #1] continues to exit seek?? c. Progress Notes ? 8-10-2022: ?[Resident #1] Continues to exhibit exit-seeking?? d. Nurse?s Notes - 9-28-2022 11 p.m. ? 7 a.m. shift: On the 25th of September 2022 ? [Resident #1] had to be redirected several times to return to [Resident #1?s] room, between the hours of 12-2:30 a.m. [Resident #1] kept exit seeking, going down the stairs near his room, which leads to the memory unit. [Resident #1] wasn?t fully dressed, tee shirt, boxers & shoes. After leaving [Resident #1?s] room for the 3rd time, I suggested we go for a walk?? 2. Resident #1?s UAI was updated 9-29-2022 with ?Exit Seeking behavior noted? however, there is not an updated ISP to reflect this identified need.
Plan of Correction:	Complete and thorough review of all ISPs and UAIs to ensure all needs are captured and addressed to reflect safety and appropriate placement. Ensure that all ISPs and UAIs are completed in the required time frame with signature reviews of responsible parties.
Standard #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: Resident #1?s ISP with dates identified as 7-25-2022 and not identified as a ?preliminary? ISP was not signed or dated by the licensee, administrator, or designee; nor by the resident or his legal representative. This ISP for Resident #1 was the only ISP of record for Resident.
Plan of Correction:	Complete a thorough review of all ISPs and UAIs to ensure all needs are captured and addressed to reflect the individual needs of each resident.
Standard #:	22VAC40-73-460-D
Description:	Based on record review and interview with staff, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises. Evidence: 1. Resident #1 admitted 7-25-2022 to the facility. The following Nurse?s Notes (by physician) documented Resident #1 wandering incidents: a. 7-31-2022 7 a.m. ? 3 p.m. shift: ?Pt. [Resident #1] was brought back to the facility @ 10:45 am from [Street Name]. [Resident #1] was pleasantly confused, [Resident #1] stated ?I am looking for my mama?? b. 8-29-2022 11 p.m. ? 7 a.m. shift: ?Resident [#1] found out front of facility by staff member around 0530 [5:30 a.m.]. Resident [#1] was able to pull open the locked sliding front door with his hands per resident [#1]? 2. Staff #1 confirmed the aforementioned incidents of wandering.
Plan of Correction:	Procedures to be developed and implemented for residents that are potential to wander ensuring appropriate placement and safety 1) Identify risk via UAI and ISP documentation 2) Plans to be put into place to ensure safety