VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Pinecrest Assisted Living Facility, LLC
709 River Ridge Road
Danville, VA 24541

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: May 3, 2023

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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/03/2023 9am until 2:30pm 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: 37 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 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, the facility failed to ensure that orientation and initial training for employees occurred within the first seven working days. EVIDENCE: 1. The records for staff 1 and 2, hired on 02/28/2023 and staff 3, hired on 04/10/2023, do not contain documentation that these employees have received an orientation and initial training.
Plan of Correction:	Staff Orientation has been developed by Staff 4 for all future hires. The orientation covers the initial ALF training items and will be completed within the first 7 days of employment. Staff 1, Staff 2, and Staff 3 completed the Initial ALF Training/Orientation on 5.24.23 with Staff 4.
Standard #:	22VAC40-73-250-D
Description:	Based on staff record review, the facility failed to ensure that a screening for tuberculosis was completed on or within seven days prior to the first day of work at the facility for all employees. EVIDENCE: 1. The records for staff 1 and 2, hire date of 02/28/2023, doe not have documentation that a screening for tuberculosis was completed prior to their first day of work. 2. The record for staff 3, hired on 04/10/2023, has documentation that a screening for tuberculosis was not completed until 04/16/2023.
Plan of Correction:	Staff 4 scheduled for Staff 1, Staff 2, and Staff 3 to have TB test completed onsite by contracted provider, GoDocs, on 5.16.23. GoDocs, reported that TB test should only be completed annually and that she would not be able to do new ones for staff whose TBs were within the year.
Standard #:	22VAC40-73-270-1
Description:	Based on staff record review, the facility failed to ensure that direct care staff received training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. EVIDENCE: 1. The record for staff 1 and 2, hired on 02/28/2023 do not have documentation of current training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states. The facility houses a mental health population including resident 3, who has a history of aggressive behaviors.
Plan of Correction:	Aggressive Behavior Training will be provided to all PineCrest employees on 6.28.23 by Staff 4. After this facility-wide training, the Aggressive Behavior Training will be part of the Initial Orientation Training to ensure staff have completed this training requirement moving forward. Staff 4 will ensure Staff 1 & Staff 2 are in this training. Staff 4 will discuss Resident 3?s history of aggressive behavior for training purposes.
Standard #:	22VAC40-73-360-A
Description:	Based on resident record review, the facility failed to ensure that an emergency placement occurred only when the emergency is documented and approved by an adult protective services worker for public pay individuals or an independent physician or an adult protective services worker for private pay individuals. EVIDENCE: 1. The record for resident 3 has documentation that the resident was admitted to the facility on 03/15/2023. A letter documenting the residents emergency placement was not obtained by an adult protective services worker for public pay individuals until 04/14/2023.
Plan of Correction:	Staff 4 created an admission checklist to ensure PineCrest obtains required documentation within the regulations specified time-frames. The check list also indicates that an Emergency Placement Letter is to be provided before or on the day of the emergency placement or otherwise the resident will not be able to be placed at PALF.
Standard #:	22VAC40-73-360-B
Description:	Based on resident record reviews, the facility failed to ensure that all required information was obtained within 7 days of admission for an emergency placement. EVIDENCE: 1, The record for resident 3 has documentation that the resident was admitted on 03/15/2023 as an emergency placement. The history and physical in the record for resident 3 was not completed until 03/27/2023 and the sex offender screening was not completed until 04/14/2023.
Plan of Correction:	Staff 4 created an admission checklist to ensure PineCrest obtain required documentation within the regulations specified time-frames. The admission check list also indicates that an Emergency Placement Letter is to be provided before or on the day of the emergency placement or otherwise the resident will not be able to be placed at PALF.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that uniform assessment instruments (UAI) for public pay individuals were completed as required. EVIDENCE: 1. The public pay UAI dated 07/19/2022 in the record for resident 4 indicates that the resident requires supervision with bathing; however, the individualized service plan (ISP) for the same resident, dated 05/18/2022, does not address bathing needs. Interview with staff 4 revealed that resident 4 does not require any assistance with bathing and that the public pay UAI is incorrect.
Plan of Correction:	Staff 4 contacted local DSS regarding resident 4 on 5.8.23. His UAI was updated 5.10.23 and provided to the Facility on 5.22.23. Resident 4?s ISP was updated on 5.23.23 by Staff 6. Both documents are now congruent and reflect that Resident 4 does not require assistance with bathing.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) included all requirements. EVIDENCE: 1. The ISP for resident 4 dated 05/18/2023, did not address the resident?s walking and mobility needs; however, the public pay UAI for the same resident, dated 07/19/2022, indicates that the resident requires the mechanical assistance of a walker for walking and mobility. Interview with staff 4 revealed that resident 4 uses a walker for his walking and mobility needs.
Plan of Correction:	Staff 4 contacted the local DSS regarding resident 4 on 5.8.23. His UAI was updated 5.10.23 but Staff 4 noticed an oversight regarding Ambulation that was not corrected. Staff 4 reached out to local DSS on 5.23.23 to have this oversight addressed, so the updated ISP & UAI will be congruent. Local DSS communicated to Staff 4 that the UAI has been corrected and placed in the mail to the facility on 5.25.23
Standard #:	22VAC40-73-640-A
Description:	Based on observation, policy review, and staff interview, the facility failed to implement parts of its medication management plan specifically regarding methods to prevent the use of outdated, damaged, or contaminated medications and methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. Regarding insulin pens, the facility?s current medication management plan states, ?Make sure when opening a new pen, the open and expiration dates are written on the pen?. While performing an audit of medication cart #2, the LI observed a opened Lantus Solostar Insulin pen for resident 5. The label on the pen stated, ?Discard after 28 days?; however, the pen did not contain an open date in order to determine the date that the pen is to be discarded. The LI interviewed staff 1 regarding the pen?s expiration date and she could not determine when the pen had been opened. 2. Regarding accurate counts of controlled medications, the facility?s current medication management plan states, ?Each oncoming shift must count controlled pills with the outgoing shift and both must sign off on the control sign log?. Resident 6 has physician?s orders for Lorazepam 0.5mg, take 1.5 tablets by mouth twice daily for anxiety. While performing an audit of medication cart #1, the LI observed that the morning Lorazepam 0.5mg pill card for resident 5 contained 27 doses of the prescribed medication; however, the corresponding controlled drug log for this medication indicated that there should be 28 doses in the pill card. An interview with staff 1 could not reconcile the count discrepancy between the pill card and the corresponding controlled drug log despite staff 5and staff 1 signing that the counts were correct on the morning of the inspection. Resident 7 has physician?s orders for Clonazepam ODT 1mg tablet, Dissolve 1 tablet by mouth at bedtime. While performing an audit of medication cart #2, the LI observed that the Clonazepam ODT 1mg tablet pill packs for resident 7 contained 17 pills; however, the corresponding controlled drug log for this medication indicated that there should be 29 pills in the pill packs. An interview with staff 1could not reconcile the count discrepancy between the pill packs and the corresponding controlled drug log despite staff 6 and staff 7 signing that the counts were correct on the morning of the inspection. 3. The April 2023 Control Sign Sheet for medication cart #1 was not signed on the following dates: on 4/25 by 2nd shift off-going staff and 3rd shift oncoming staff; on 4/26 by 3rd shift off-going staff; on 4/28 by 3rd shift oncoming staff; and on 4/29 by the 3rd shift off-going staff. The April 2023 Control Sign Sheet for medication cart #2 was not signed on the following dates: on 4/22 by the 1st shift off-going staff and on 4/27 by the 1st shift oncoming staff.
Plan of Correction:	Staff 4 reviewed the Medication Management Plan with Staff 1 and Staff 7 on 5.3.23 following state inspection. On 5.3.23, Staff 4 also observed the off-going & oncoming staff during shift exchange to ensure compliance with the Medication Management Plan. Staff 4 reviewed the Medication Management Plan again on 5.10.23 with Staff 1, Staff 2, Staff 5, Staff 6 and the other RMA staff. Staff 4 consulted with the Pharmacy about observing medication passes and retraining RMA staff. The training is scheduled for 6.5.23. Staff 4 has also randomly observed ongoing medication passes to ensure compliance with the Medication Management Plan. Staff 4 contacted the local sheriff?s department on 5.3.23 to report the drug diversion. Staff 4 spoke with Deputy. Staff 4 contacted Pharmacy on 5.5.23 to discuss the drug diversion and process for re-ordering the missing medications for Resident 7. Staff 4 reached out to Resident 7?s prescribing provider on 5.5.23. Prescribing provider contacted Staff 4 on 5.8.23 and confirmed she would refill her script. Resident 7?s new script arrived on 5.10.23. Staff 4 discussed and reviewed with Staff 1 Resident 5?s insulin pen. Staff 1 discussed with other RMA staff and reviewed records to determine when the pen was opened. Staff 1 wrote when the pen is to be discarded, 6.1.23. Staff 1 addressed this on 5.5.23. Staff 4 addressed with Staff 1 the medication audit performed on cart #1 and her oversight in counting and documenting the appropriate medication count after she administered medication to Resident 6. Staff 4 addressed the counting error on the eMar. Staff 4 documented on the eMAR the counting errors and the new medication count for Resident 6 & Resident 7. Staff 4 hired an LPN and a National Pharmacist Technician. Both started on 5.15.23, to help ensure best practices with medication management.
Standard #:	22VAC40-73-750-E
Description:	Based on observations of the facility physical plant, the facility failed to ensure that the sheets on resident beds were clean. EVIDENCE: 1. The bed linens on the bed in room 12 were noted to be soiled/stained on the day of inspection.
Plan of Correction:	Staff 4 had housekeeping clean and replace soiled/stained linens in Room 12 on 5.3.23. Staff 4 has added Room 12 to the housekeeping daily list for ensuring clean linens. Staff 4 discussed with resident in Room 12 on 5.3.23 making his cigarettes outside instead of on his bed. Staff 4 has continued to randomly check in with resident in Room 12 to make sure he remembers to make his cigarettes outside.
Standard #:	22VAC40-73-860-I
Description:	Based on observations of the facility physical plant, the facility failed to store cleaning supplies in a locked area. EVIDENCE: 1. Room 28 was observed to have a container of Chases Clean Home Spray Disinfectant sitting out on the bed side table of the first bed. 2. Room 31 was noted to contain a container of Sani Cloth Disinfectant Wipes and a can of SC Johnson Scrubbing Bubbles sitting out on the sink cabinet by the first bed in the room. 3. A bottle of Glass Cleaner was observed sitting out on the fireplace mantle by the kitchen. 4. The cabinet under the kitchen sink was noted to be unlocked and multiple cleaning supplies were observed in the cabinet. The kitchen was unattended at the time the LI made these observations.
Plan of Correction:	On 5.3.23 Staff 4 did a walk-through of the Facility and locked the cleaning supplies up in the locked supply closet. Staff 4 discussed with Resident in Room28 keeping all cleaning supplies in inconspicuous locations like his closet or under his sink. Resident in Room 28 put the disinfectant spray on the top shelf in his closet. On 5.24.23 Staff 4 discussed this with all residents in the Resident Meeting. On 5.4.23 Staff 4 sent out a memo to all PALF staff reminding all staff that cleaning supplies are to be locked up. Staff 4 communicated that the cleaning supplies under the kitchen have also been relocated to locked supply closet until a lock is provided for the kitchen sink. Staff 4 educated staff on capable residents having access to cleaning supplies but such supplies needing to be out of sight for residents that are not capable to have access. On 5.10.23, Staff 4 addressed these issues again with All Staff and the contracted Cleaning Services in the All Staff Meeting. Staff 4 implemented a procedure for Environmental Services and the contracted Cleaning Services to do daily sweeps to ensure all cleaning supplies are safely locked up.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record reviews, the facility failed to ensure that a criminal history record review was completed prior to the 30th day of employment for new employees. EVIDENCE: 1. The record for staff person 1, hired on 02/28/2023, has a criminal record check that was not completed until 04/25/2023. 2. The record for staff person 2, hired on 02/28/2023, did not have documentation that a criminal record check has been completed for this employee.
Plan of Correction:	Staff 4 established a new check list to ensure background checks are completed and sent off within 30 days of employment. Staff 4 completed the process to become a notary and had a designee also complete the process to become a notary, to ensure background checks are notarized and sent off timely.