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: Jan. 9, 2023

Complaint Related: Yes

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1-09-2023, 12:00 p.m. ? 1:45 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on October 26, 2022 regarding allegations in the areas of: General Provisions; Administration and Administrative Services; Personnel; Staffing and Supervision; Admission, Retention and Discharge of Residents; Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 87 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Administration and Administrative Services; Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-40-A
Complaint related:	Yes
Description:	Based on record review and interview with staff, the facility failed to ensure compliance with the facility?s own policies. Evidence: 1. Policy Number 050-050 titled, ?Confused & Wandering Residents? dated 5-01-2017 documented, ?Individuals identified as confused or potentially wandering residents (?wanderers?) will be expected to wear identification bracelets.? 2. Resident #1 admitted 7-25-2022 and was identified on physician?s orders dated 7-31-2022 ?Advise 24 h sitter c? [with] exit seeking?. An additional progress note by the physician dated 8-05-2022 documented, ?...continues to exit seek?. 3. Interview with Staff #2 confirmed that Resident #1 exhibited wandering and exit-seeking behaviors from prior to his admission to the Assisted Living Facility (ALF), when he resided in Independent Living at the same community, and that his wandering and exit seeking behaviors continued until the time of his discharge from the ALF. 4. Staff #1 confirmed that Resident #1 did not wear an identification bracelet during his admission to the ALF from 7-25-2022 to 10-05-2022.
Plan of Correction:	Review Policy 050-050 to ensure identification bracelets are accessible for ?potential wandering residents?. Review with staff the policy and process.
Standard #:	22VAC40-73-450-A
Complaint related:	Yes
Description:	Based on record review and interview, on or within seven days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: 1. Resident #1 admitted 7-25-2022. Resident #1?s ISP in the record with dates identified of needs as 7-25-2022 was not identified as the preliminary plan of care. 2. Additionally, Resident #1?s ISP did not document concerns for resident?s behaviors regarding exit-seeking or wandering behaviors; however, documentation in the Nurse?s Notes dated 7-22-2022 and Physician?s Progress Notes dated 8-05-2022 documented exit-seeking behaviors, as well as interviews with Staff.
Plan of Correction:	Complete a 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 #:	22VAC40-73-650-B
Complaint related:	No
Description:	Based on record review, the facility failed to ensure physician or other prescriber orders included the identification of the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. Resident #1?s physician?s orders dated 9-28-2022 documented, ?Seroquel 25 mg tablet... ? tab nightly for 1 week?? and did not identify the diagnosis, condition, or specific indications for administering the drug. 2. Resident #1?s physician?s orders dated 7-29-2022 documented, ?Aveed 750 mg/3mL Inject 3mL IM once every 10 weeks? and did not identify the diagnosis, condition, or specific indications for administering the drug.
Plan of Correction:	All MAR audit review to ensure physician orders identify - Diagnosis - Condition - Specific indications for administering drugs/ medications. Will utilize our Pharmacy to assist with this oversight.
Standard #:	63.2-1808-A
Complaint related:	Yes
Description:	Based on record review and interviews, the facility failed to ensure any resident of an assisted living facility has the rights and responsibilities enumerated in this section, including freedom to select health care services from reasonably available resources. Evidence: Resident #1 admitted to the facility on 7-25-2022 under the care of Physician #1. The facility implemented a change of physician for Resident #1 without the consent of the Power of Attorney [POA]. A family member who was not the POA for Resident #1 offered consent for the change of physician.
Plan of Correction:	Educate staff that only POA has the authority to give consent for change of physician