VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Town Creek Assisted Living Facility
393 Front Street
Lovingston, VA 22949
(434) 263-4313

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: June 5, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/05/2024 8am until 12:30pm 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: 55 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-120-A
Description:	Based on staff record review and staff interview, the facility failed to ensure the orientation occurred within the first seven working days of employment for a staff member. EVIDENCE: 1.The record for staff person 3, hired on 3/5/2024, did not contain documentation that this employee received orientation within the first seven working days of employment. 2. The record for staff person 6, hired on 10/03/2023, did not contain documentation that this employee received orientation within the first seven working days of employment. 3.In an interview with staff person 8 on 6/5/2024, staff person 8 indicated there was no documentation for orientation for staff persons 3 or 6.
Plan of Correction:	Orientation paperwork has been placed into the charts. Administrator and program manager will ensure that the orientation paperwork is completed and place into the file. Date fixed 6/6/24.
Standard #:	22VAC40-73-450-F
Description:	to ensure that individualized service plans (ISP) were updated as needed for a significant change in a residents condition. EVIDENCE: 1. The record for resident 3 has documentation of a physician order dated 04/08/2024 for Home Health Nursing for wound care to the residents left foot. The ISP dated 04/04/2024 in the record for resident 3 does not address this change or identify services to be provided for this identified need.
Plan of Correction:	We receiving and order for wound care the isp will be updated to reflect the change in condition. Staff will place copies of the orders in the Administrator and program managers inboxes for review and to ensure the ISP has been updated. Date correct 6/5/24
Standard #:	22VAC40-73-470-B
Description:	Based on resident record review and staff interviews, the facility failed to ensure that a resident's need for skilled nursing treatments within the facility were met by the facility's employment of a licensed nurse or contractual agreement with a licensed nurse, or by a home health agency or by a private duty licensed nurse. EVIDENCE: 1. The record for resident 3 has a physician order dated 04-08-2024 for Home Health Nursing: wash and soak both feet for 3 minutes using Dakin?s 0.25% Solution three times weekly. Pat dry and apply a dry dressing to left foot wound. The record for resident 3 does not have any documentation that Home Health Nursing has been providing this skilled nursing treatment. In an interview with staff person 1, 4, and 8 it was expressed that Home Health Nursing has not been in for the treatment to resident 3?s left foot.
Plan of Correction:	Wound care order will be placed into the administrator, program managers, and nursing coordinator inboxes to follow up on and ensure that the referrals have been sent out and wound care has been scheduled with a home health company. Date corrected 6/5/24
Standard #:	22VAC40-73-860-I
Description:	Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area. EVIDENCE: 1. A container of Clorox Disinfecting Wipes was noted sitting out on the handrail in the hallway next to room 23. 2. A container of Clorox wipes was noted sitting on the sink counter in the unlocked staff bathroom across from the nursing office. 3. A bottle of Xcelente Multi-Purpose Cleaner was observed sitting on the floor outside of the staff bathroom across from the nursing office.
Plan of Correction:	Cleaning supplies have been removed from those areas and will only be kept in the cleaning closest, locked cleaning carts, and locked in the nurses station. Date corrected 6/5/24
Standard #:	22VAC40-73-870-A
Description:	Based on observations of the facility physical plant, the facility failed to maintain the interior of the building in good repair and kept clean. EVIDENCE: 1. The carpet in the activity/puzzle room was noted to have numerous stains throughout the room on the day of inspection.
Plan of Correction:	Carpet will be replaced.
Standard #:	22VAC40-73-990-B
Description:	Based on facility documentation review, the facility failed to ensure that procedures in the plan for resident emergencies was reviewed by the facility at least every six months with all staff. EVIDENCE: 1. Documentation of the facility review of procedures for resident emergencies dated 05/08/2024 has that the only procedure reviewed was for missing residents.
Plan of Correction:	Resident emergencies in services have been updated to include all domains that need to be practiced. Corrected 6/5/24
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review and staff interview, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The record for staff person 6, hired on 10/03/2023, contained documentation that a criminal history report was not completed for this employee until 12/04/2023. 2. The record for staff person 7, hired on 08/07/2023, contained documentation that a criminal history report was not completed for this employee until 10/12/2023. 3.In an interview with staff person 8 on 06/05/2024, staff person 8 indicated those were the correct dates for the criminal history reports for staff 6 and 7.
Plan of Correction:	Request for Criminal histories will be sent within 30 days of hire. Administrator and or Program manager will work with HR to obtain criminal histories. Date corrected 6/5/24