VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Auburn Hill at Swift Creek
5800 Harbour Lane
Midlothian, VA 23112
(804) 250-5740

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: July 20, 2023

Complaint Related: No

Areas Reviewed:

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: 7-20-2023, 9:01 ? 10:40 a.m. Number of residents present at the facility at the beginning of the inspection: 71 Number of resident records reviewed: 4 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 4/21/2023 and 5/15/2023 regarding allegations in the area of: Resident Care and Related Services The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-440-A
Description:	Based on record review, the facility failed to ensure that the uniform assessment instrument (UAI) was completed at least annually. Evidence: Resident #4 admitted 4-23-2021. Resident #4?s latest UAI was dated 3-11-2022. Resident #3 admitted 4-22-2021 and was discharged 5-24-2023. Resident #3?s latest UAI was 4-22-2021.
Plan of Correction:	Facility will ensure that UAI (uniform assessment instrument) will be completed at least annually and or a change in condition. The UAI?s will be the responsibility of our Memory Care Director and/or our Director of Health and Wellness. Resident #4?s latest UAI was dated 08/09/23. Resident #3 no longer resides in the community. A weekly audit will be completed for the next 30 days by the Director of Health and Wellness and Director of Memory Care to ensure that all UAIs are up to date.
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 resident or his legal representative. Evidence: Resident #1 admitted 1-29-2020. Resident #1?s ISP dated 4-13-2022 was not signed by the resident or resident?s legal representative.
Plan of Correction:	Facility will ensure that the ISP (Individualized service plan) will be signed and dated by the resident or his/her legal representative. It will be the responsibility of our Memory Care Director and/or our Director of Health and Wellness. Resident #1 no longer resides in the community. A weekly audit will be completed for the next 30 days by the Director of Health and Wellness and Director of Memory Care to ensure that all individualized service plans (ISPs) are up to date and have been reviewed and signed by resident and/or legal representative. Weekly audit by ED, HWD , and DIMC conducted for next 30 days.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months. Evidence: Resident #4 admitted 4-23-2021. Resident #4?s most current ISP was dated 5-13-2022.
Plan of Correction:	Facility will ensure that ISP?s (Individualized service plan) will be reviewed and updated al least once every 12 months and as needed for a significant change of a resident?s condition. This will be the responsibility of our Memory Care Director and/or our Director of Health and Wellness. Resident #4?s latest UAI was dated 08/09/23. A weekly audit will be completed for the next 30 days by the Director of Health and Wellness and Director of Memory Care to ensure that all individualized service plans (ISPs) are up to date and have been reviewed and updated at least once every 12 months.
Standard #:	22VAC40-73-470-F
Description:	Based on record review and interview with staff, when the resident suffers serious illness or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately. Evidence: 1. Resident #1 admitted 1-29-2020 to the facility. Resident #1?s Progress Notes dated 4-17-2023 documented, ?Physical therapist states she noticed a decline in the resident from Friday to today (4/17), she reports [Resident #1] not following instructions as well, seems weaker, and her voice was hoarse. She also observed the resident choke on water which she had never observed before. She states her vitals were good and to push fluids in case of dehydration.? 2. On 4-22-2023, Progress Notes documented the resident was ?lying in bed breathing using accessory muscles, will open eyes briefly when name is called but is unable to say any words. Large area below left ear hardened and slightly warm to touch. Ear lobe swollen as well. Left hand and fingers purple and swollen? also has purplish blotching discoloration to bilateral lower extremities?transported to [hospital] via EMS?? 3. Resident #1 was admitted to the hospital on 4-22-2023 with ?altered mentation and fever and was admitted with a diagnosis of metabolic encephalopathy, septic shock, renal failure, parotitis, and pneumonia.? 4. Resident?s 4-27-2023 facility Progress Note documented, ?[Staff] spoke with daughter-in-law about resident?s status, [Resident #1] is in ICU in serious condition?stated she e-mailed Director of Innovations and never received a response.? 5. There was no documentation that Resident #1?s physician was contacted following a 4-18-2023 physician?s note regarding Resident #1?s [bilateral extremities] and bruise on chest. Additionally, Staff #1 confirmed during interview that Resident #1 had a delay in medical care from 4-17-2023 to 4-22-2023 as medical attention was not secured immediately. Progress Notes documented Resident #1 passed under hospice on 4-29-2023.
Plan of Correction:	Resident #1 was seen by a physician on 04/18/23 due to a change in the resident?s medical condition. Resident #1 no longer resides in the community. All residents who suffer a serious illness or medical condition will be reviewed by the Director of Health and Wellness (DHW)/Director of Memory Care (DMC) in stand-up meeting daily to ensure that medical attention from a licensed health care professional is secured timely.
Standard #:	22VAC40-73-550-C
Description:	Based on record review and interview with staff, the facility failed to ensure any resident of an assisted living facility (ALF) has the rights and responsibilities as provided in ? 63.2-1808 of the Code of Virginia and this chapter. Evidence: 1. Three self-reported incidents were received by Staff #1 on Residents? #2, #3, and #4 that alleged abuse took place between approximately 4-08-2023 and 4-21-2023. 2. A `Comment/Concern? form completed by Staff #6 documented that (on unknown date), ?[Staff #7] and [Staff #6] worked 11-7 shift in memory care unit? [Resident #2] is usually agitated... [Staff #7] took the resident blue diaper off resident, the diaper was soaking with which the diaper inflated heavily with urine. [Staff #6] saw [Staff #7] took the diaper and hit resident in the face?? 3. A `Skin Integrity Monitoring? form completed by Staff #8 dated 4-21-2023 documented no injuries to Resident #2. Eight staff written statements denied witnessing abuse by Staff #7 at any time or this alleged incident. 4. A `Witness Statement? form completed by Staff #4 dated 4-19-2023 documented, ?approx. 4/8/23? [Staff #5] asked for assistance with [Resident #3]. [Staff #5] told [Resident #3] several times to ?get the f*** up? then she proceeded to closed fist hit [Resident #3] in the groin. On multiple other shifts she was heard yelling at residents in the dining area to leave and ?get the hell up?, ?get the f*** up??? 5. The aforementioned witness statement by Staff #4 additionally documented, ??On approx. 4/14/23 [Staff #5] was also observed in dining area? trying to get [Resident #4] out of the area? gave [Resident #4] terrible attitude and pushed his walker to him, he got mad and called her an a**hole, she called him one as well and pushed the walker again, she walked off taunting and laughing at him?? 6. Skin Integrity Monitoring Forms completed by Staff #8 dated 4-20-2023 documented no injuries to Resident #3 or Resident #4. 7. Staff #5 was terminated per Staff #1 due to substantiated footage seen by Staff #1 and Staff #2 involving incident with Resident #4. Staff #1 and Staff #2 stated that Resident #2?s and Resident #3?s incidents could not be substantiated due to lack of witnesses or camera evidence (none seen). Staff #6 who made allegations regarding Resident #2 ?quit a couple days ago? and was written up for reporting incidents late to staff.
Plan of Correction:	A major incident report/investigation for allegation of abuse and neglect for Resident #2 was completed on 04/21/23 by the Executive Director. A major incident report/investigation for allegation of abuse and neglect for Resident #3 was completed on 04/20/23 by the Executive Director. A major incident report/investigation for allegation of abuse and neglect for Resident #4 was completed on 04/20/23 by the Executive Director. Staff member #5 was terminated for abuse and neglect. All staff were re-educated on abuse and neglect mandated reporter status by the Executive Director. All staff were re-educated on Residents rights and responsibilities as provided in 63.2-1808 of the Code of Virginia and this chapter on 09/19/2023. Resident?s rights and responsibilities as provided in 63.2-1808 of the Code of Virginia and this chapter will be reviewed upon hire and annually.