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: Aug. 21, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 EMERGENCY PREPAREDNESS

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: 8-21-2023, 9:11am ? 1:00pm 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: 71 Number of resident records reviewed: 10 Number of staff records reviewed: 3 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-440-B
Description:	Based on record review, the facility failed to ensure an assisted living facility staff person who has completed the uniform assessment instrument (UAI) has it signed by the administrator or the administrator's who approves and then signs the completed UAI. Evidence: Resident #9?s UAI dated 10-07-2022 and Resident #10?s UAI dated 9-29-2022 were only signed by former director of memory care, and not by the administrator or designee as having approved the UAIs.
Plan of Correction:	Facility will ensure that the staff person completing the UAI (uniform assessment instrument) will sign and date it and will make sure that the administrator or administrator?s designee also signs and dates for approval of the completed UAI.
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 and date identified based upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources. Evidence: 1.Resident #2 admitted 6-21-2023. Resident #2?s Uniform Assessment Instrument (UAI) dated 8-08-2023 documented wheeling and stairclimbing assistance as ?human help, physical assistance? and that resident is disoriented; however, those needs were not identified on the comprehensive ISP dated 8-08-2023. The resident resided in the special care unit (SCU) which was not on the resident?s ISP. 2.Resident #7 admitted 4-28-2023. Resident #7?s UAI dated 6-22-2023 documented transferring assistance as ?mechanical help, human help physical assistance? and that resident is disoriented; however, those needs were not identified on the comprehensive ISP dated 8-03-2023. The resident resided in the SCU, which was also not on the resident?s ISP. 3.Resident #8 admitted 5-16-2023. Resident #8?s UAI dated 6-16-2023 documented behaviors as ?wandering?; however, the ISP dated 6-16-2023 did not identify this service need.
Plan of Correction:	Facility will ensure that the comprehensive individualized service plan (ISP) shall include description of identified needs and date identified based upon the UAI (uniform assessment Instrument), admission physical examination, interview with resident, fall risk rating and if appropriate assessment of psychological, behavioral, and emotional functioning and other sources. This will be the responsibility of our Memory Care Director and/or our Director of Health and Wellness. Resident # 2- Deceased on 08/21/2023 Resident # 7- Deceased on 9/14/2023 Resident #8- ISP updated on 11/01/2023 An audit of all resident UAIs and ISPs will be conducted to ensure all needs assessed on the UAI are captured on the ISP. Director of Health and Wellness will provide all individuals completing UAIs a copy of the UAI manual. ED will ensure prior to all resident signatures that all assessed needs on the UAI are captured in the ISP.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to ensure individualized service plans (ISPs) were updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. Resident #10 admitted 2-15-2022. Resident #10?s UAI dated 9-29-2022 documented the resident has wandering behaviors; however, the most recent ISP 9-2022 did not identify wandering behavior. The resident also resided in the Special Care Unit (SCU); however, it was not addressed on the ISP. 2.Resident #9 admitted 2-15-2021. Resident #9?s UAI dated 10-2022 identified the resident as bowel and bladder incontinent, weekly or more; however, the ISP dated 8-22-2023 documented the resident as ?continent?. Additionally, the resident?s UAI documented the resident has wandering behaviors and is disoriented, which neither were addressed on the ISP. 3.Resident #6 admitted 2-25-2022. Resident #6?s UAI dated 10-04-2022 documented the resident has bowel incontinence; however, the ISP dated 8-25-2023 documented ?continent?. 4.Resident #1 admitted 2-01-2022. Resident #1?s UAI dated 3-29-2023 documented the resident requires ?mechanical help, human help physical assistance? with bathing, and ?mechanical help, human help supervision? with transferring; however, neither need was addressed on the ISP dated 3-28-2023.
Plan of Correction:	Facility will ensure that ISP?s (Individual service plan) will be reviewed and updated at 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 #10- updated on 11/01/2023 for Assessment and care plan to match Resident # 9- updated on 11/01/2023 for UAI to match ISP Resident #6- updated on 11/01/2023- for UAI to match ISP Resident #1- updated on 11/01/2023 for UAI to match ISP
Standard #:	22VAC40-73-970-E
Description:	Based on record review, the facility failed to ensure a record of the required fire and emergency evacuation drills included the number of residents participating. Evidence: The 5-29-2023 Fire and Emergency Evacuation Drill at 10:30 p.m. was blank under ?Number of residents participating:?.
Plan of Correction:	Facility will ensure that a record of the required fire and emergency evacuation drills include the number of residents participating. This will be the responsibility of our Director of Environmental Services or the Director of Environmental Services assistant/designee.