VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Hamilton
113 Battle Road
Yorktown, VA 23692
(757) 898-1491

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: March 7, 2023 , March 9, 2023 and March 16, 2023

Complaint Related: No

Areas Reviewed:

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal An unannounced, on-site renewal inspection was conducted on two days, day one (Ar 07:30/ dep 4:55 p).The facility census was 38. A tour of the facility was conducted, a medication pass observation conducted, staff and resident interviews and record reviews conducted, emergency preparedness documents and supplies reviewed/ observed. The breakfast meal was observed and the library activity observed. Staff records were reviewed completed on day two. A preliminary exit meeting was conducted on both days. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure that the comprehensive individualized service plan (ISP) included all assessed needs for three of eight residents? record. Evidence: 1. On 3-7-23, resident #2?s uniformed assessment instrument (UAI) dated 10-18-22 and completed and signed by staff #3 and #1 documented bathing need as no help. The individualized service plan dated 9-30-22 documented, ?assistance with bathing mechanical?shower bench/seat for additional stability and safety during bathing?. Orientation assessed as, ?disoriented some spheres -some time?place/time?. This need was not documented on the ISP. The resident?s admitting physical examination dated 9-2-22 (signed 9-7-22) documented PT/OT evaluations. The therapy documents provided by staff #3 on 3-7-23 documented skilled nursing, physical therapy and occupational therapy services; start of care (SOC) 10-20-22 to 12-18-22. Physical therapy discontinued 12-1-22, skilled nursing discontinued 11-16-22 and occupational therapy discontinued on 10-24-22. These services were not documented on the ISP. Resident?s date of admission documented as 9-28-22. 2. Resident #3?s UAI dated 9-28-22 and completed and signed by staff #3 and #2 documented bathing need as no help. The ISP dated 9-30-22 documented, ?assistance with bathing mechanical? shower bench/seat for additional stability and safety during bathing?. Resident?s date of admission documented as 9-28-22. 3. Resident #6?s UAI dated 2-14-23 and completed and signed by staff #8 and #1 documented eating/feeding assessed as no help. The ISP dated 2-17-23 documented, ?assistance with eating. Staff will provide reminders at mealtimes, set up tables, assist with cutting up food, opening containers and telling resident what is served?. Resident?s physical examination form 1-31-23 documented resident has dentures, partial upper and lower. This assessed need not on the ISP. The record did not include a signed and dated Do Not Resuscitate (DNR)document. The ISP and facility face sheet documented resident is a DNR. Resident?s date of admission dated as 2-15-23. 4. Staff #3 acknowledged the assessed needs and services were not documented on the ISP.
Plan of Correction:	1. The Director of Nursing/ designee reviewed and corrected the UAI?s and ISP?s as appropriate for resident #2, resident #3, resident #6, to accurately reflect and identify the current needs of the residents with appropriate time frames for services needed. Resident #6 has a signed and dated DNR form in place. 2. Resident Coordinator had been re-educated to ensure that all resident?s UAI?s and ISP?s correspond and correctly identify and document the care needs of residents simultaneously, to include identifying correct time frames for services that residents need. 3. The Director of Nursing/designee will conduct a weekly audit for six weeks of resident?s UAI?s and ISP?s to ensure that UAI?s and ISP?s accurately reflect resident?s needs. The Director of Nursing/ Designee will review audit results for patterns and trends and report findings to the leadership team. Date of Correction: March 21, 2023
Standard #:	22VAC40-73-450-F
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure that the individualized service plans shall be reviewed and updated at least annually once every 12 months and as needed for a significant change of a resident?s condition and included assessed needs for two of eight residents? record. Evidence: 1. On 3-7-23, resident #4?s UAI dated 12-21-22, completed and signed by staff #8 and #2 documented mobility with supervision. The ISP dated 12-21-23 documented, ?no assistance?. The ISP did not include expected outcome and time frame for expected outcomes. Resident?s date of admission documented as 11-25-18. 2. Resident #5?s UAI dated 1-17-23, completed and signed by staff #8 and #1 documented stairclimbing need assessed as physical assistance. This need was not documented on the ISP dated 1-27-23. Resident?s date of admission documented as 5-20-22. 3. Staff #3 acknowledge the ISP did not include the assessed need.
Plan of Correction:	1. The ISP for resident #4 and resident #5 were corrected to reflect the resident?s appropriate assistance needed per the UAI. Resident #4?s ISP had also been corrected to include the time frame for expected outcomes. 2. Resident Coordinator had been re-educated to ensure that all resident?s UAI?s and ISP?s correspond and correctly identify time frame for expected outcomes. 3. The Director of Nursing/ designee will audit ISPs for any resident with a change in their condition monthly for a period of three months to ensure that any changes in a resident?s condition are updated in the ISP if needed. The Director of Nursing/ Designee will review audit results for patterns and trends and report findings to the leadership team. Date of Correction: March 21, 2023
Standard #:	22VAC40-73-470-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure, either directly or indirectly, health care services need of a resident is met for one of eight residents. Evidence: 1. On 3-7-23, resident #3,?s admitting physical examination document dated 9-2-22 documented physical therapy (PT)/occupational therapy (OT) evaluation. The resident?s record and individualized service plan did not include documentation of these services. 2. Staff #1, #3 and #9 acknowledged the resident?s services not provided as it was not needed. The record did not include documentation of a discontinued order for services not needed.
Plan of Correction:	1. Resident #3?s record was updated to show the physical therapy order was discontinued per provider?s assessment of resident and order. 2. Nursing staff will be educated on ensuring that therapy orders are initiated and/or discontinued as appropriate and properly documented in their record once therapy is completed. 3. Director of Nursing/ designee will perform weekly audits for six weeks to review and ensure physical therapy orders are correctly documented in resident?s physician orders. Audit results will be reviewed for patterns and trends and findings reported to the leadership team. Date of Correction: March 21, 2023