VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Spring Arbor of Salisbury
14001 Turnberry Lane
Midlothian, VA 23113
(804) 897-2727

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: Sept. 12, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73- (6) Resident Care and Related Services

Technical Assistance:

It is suggested that the facility update the resident agreement and/or disclosure statement to include the facility'scurrent protocol regarding wound care by facility staff and meals for hospice residents.

Comments:

Type of inspection: Complaint. Date of inspection and time the licensing inspector was on-site at the facility for the inspection: 9/12/22 10 a-4 pm The Acknowledgement of Inspection form was provided on the date of the inspection. Technical Assistance: It is suggested that the facility update the resident agreement and/or disclosure statement to include the facility's current protocol regarding wound care by facility staff and meals for hospice residents. Additional Comments: A complaint was received by VDSS Division of Licensing on 8/16/22 regarding allegations in the area of Resident Care and Related Services. Two licensing representatives were present during the inspection. Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the resident?s room. Number of resident records reviewed: 1 Number of staff records reviewed:0 Number of interviews conducted with residents:1 Number of interviews conducted with staff: 3 Observations by licensing inspector: lunch meal An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported one of the allegations; the area of non-compliance with standards or law was: Resident Care and Related Services - Physician Orders. A violation notice was issued; any violation 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 Yvonne Randolph, Licensing Inspector at 804-441-1180 or by email at yvonne.randolph@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on a review of the individualized service plan (ISP) for resident # 1, the ISP for the facility was not updated for three significant changes in the condition of the resident. Evidence: 1. The hospice plan of care for the resident approved 8/29/22 document that the resident signed a Do Not Resuscitate (DNR) order The facility ISP was last updated on 7/25/22 and state - Full Code. 2. Resident reported on 9/12/22 that all meals are provided in her room. The facility ISP updated 7/25/22 document meals are provided in two settings - the dining room and the resident room. 3. The hospice plan of care for the resident approved 8/29/22 has a physician order for an APP (alternating pressure) mattress. 4. The current ISP was not updated to address the DNR, meals being provided in the room of the resident and the use of the APP mattress.
Plan of Correction:	1. RCC will receive a copy of the plan of care upon admission from the hospice provider and ensure all changes are reflected on the ISP for resident. *ISP for resident #1 was accurate regarding status of DNR during inspection on 9/12/22. Hospice provider noted DNR on file, however, documentation was never signed by physician and was not provided to community until 9/16/2022, therefore, full code was accurate on ISP at time of inspection. 2. Documentation will be completed for all residents receiving meals in their rooms. ISP will also reflect meals being served in resident?s room and signed by RCC/ED and the resident. 3. Plan of care from hospice provider will be received upon admission and physician orders will be reflected on the ISP. *Resident declined the use of APP mattress due to her choice of sleeping in her recliner.
Standard #:	22VAC40-73-470-C
Complaint related:	No
Description:	Based on a review of the hospice plan of care and interviews with resident # 1 and facility staff on 9/12/2022, the facility failed to implement a physician order for services to prevent clinically avoidable complications i.e pressure ulcer development or worsening of an ulcer. Evidence: 1. There is a physician order dated 8/29/2022 for an APP mattress for multiple Stage 3 and DTI (deep tissue injury) wounds. 2. Facility staff reported on 9/12/22 that the resident prefers sleeping in a recliner vs. using the APP mattress and the current ISP for the resident document that the resident sleeps in a recliner. 3. The physician order does not address sleeping in the recliner. 4. There was no documentation found during the review to support that physician order for the APP mattress has been changed/modified by the prescribing physician or that the prescribing physician has been informed of the use of the recliner.
Plan of Correction:	1. RCC will receive a copy of the plan of care upon admission from hospice provider and ensure all physician orders are accurately addressed and reflected on ISP,
Standard #:	22VAC40-73-580-B
Complaint related:	No
Description:	Based on a review of the file for resident # 1 by two licensing representatives, the facility did not have a written agreement signed and dated by th e resident and the licensee or administrator forth e option of meals being served in the resident?s room. Evidence: 1. Resident # 1 reported during an interview with two representatives of VDSS licensing on 9/1//22 that all meals are served in her room. 2. Licensing staff was informed by the facility?s administrator that the required agreement is part of the resident?s admission agreement with the facility. 3. A review of the section of the admission agreement describing room service was requested and emailed to the licensing inspector for review on 9/13/22. It states ? Room service may be utilized on a short term basis due to illness or other medical emergency with approval of the Resident Care Coordinator or her assistant?. The approval was not provided or found during the file review.
Plan of Correction:	A separate document will be completed to address serving meals in the resident?s room. ISP will also reflect meals being served in resident?s room and signed by RCC/ED and resident.