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: July 26, 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 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 of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/26/2023 9:10am until 5:00pm 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: 36 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: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 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 #:	22VAC40-73-100-C-1
Description:	Based on observations of the facility medication carts and review of facility policies, the facility failed to implement its infection control policy regarding CDC recommendations for blood glucose monitoring practices. EVIDENCE: 1. The facility?s infection control policy, effective June 2023, states the following regarding Point-of-Care Blood Glucose Testing: ?Glucose meters are not to be shared between residents, and should be dedicated for single-resident use ? Glucose meters must be labeled with resident information.? 2. While performing an audit of the facility?s medication carts, it was observed that the individual glucometers for resident 6 and resident 7 were not labeled with each resident?s name.
Plan of Correction:	Residents 6 & 7 names were written on their individual glucometers with a black sharpie on 7.26.23 following the inspection. The Administrator discussed this violation with the Nursing and RMA staff during the 8.9.23 staff meeting. The Administrator also added a weekly chore (Tuesday for day shift & Saturday for evening shift) in RTasks for Nursing/RMA Department to check the glucometers to ensure the individual meters and bags are appropriately labeled. The Administrator contacted the pharmacy on 8.9.23 to have them send sticker labels to be used on the glucometers. The sticker labels arrived on 8.10.23.
Standard #:	22VAC40-73-250-D
Description:	Based on staff record review, the facility failed to ensure that on or within seven days prior to the first day of work at the facility all staff submitted the results of a risk assessment, documenting the absence of tuberculosis. EVIDENCE: 1. The record for staff 2, hired on 02/22/2023, contained a most recent tuberculosis risk assessment form which was dated 03/11/2022.
Plan of Correction:	Staff 6 informed Staff 2 of expired TB and requested Staff 2 get a new one. Staff 2 provided negative TB on 7.31.23. To ensure this does not occur again, Staff 6 and Administrator have started adding TB dates to RTasks so RTasks will provide an alert when a TB test is about to expire. Staff 6 & Administrator will then notify the appropriate staff.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure that a resident?s report of physical examination form contained all required information. EVIDENCE: 1. The report of physical examination form for resident 5, dated 06/05/2023, was incomplete in the following areas: address, telephone number, height, weight, blood pressure, and resident?s ability to self-administer medications.
Plan of Correction:	The Administrator notified Resident 5?s provider, via email on 7.27.23, of the incomplete sections on resident 5?s H&P and requested the incomplete sections be completed and the H&P returned. Provider returned Resident 5?s completed H&P on 8.2.23. Administrator discussed this with Nursing/RMA/DCS Department during the 8.9.23 staff meeting and informed them to return any incomplete H&P?s to the provider for the provider to complete. Moving forward, Staff 6 and the Administrator will do fidelity checks of all admission documents to ensure they are completed. A chart audit was completed by the Administrator and Staff 6 on 8.2.23.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review, the facility failed to ensure that uniform assessment instruments (UAIs) were completed as required. EVIDENCE: 1. The public pay UAI dated 07/05/2023 in the record for resident 1 is incomplete as it has documentation that the resident requires ADL assistance with bathing, dressing and transferring but the UAI does not identify what type of assistance is needed.
Plan of Correction:	The Administrator notified Case Manager & Assessor that completed Resident 1?s UAI, via email on 7.26.23, of the incomplete sections on his UAI. The Administrator requested that the Case Manager/Assessor include the type of ADL assistance Resident 1 needs. Case Manager/Assessor completed an addendum to address the incomplete sections on 8.11.23, during scheduled site visit.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to ensure that all required information was included when individualized service plans (ISPs) are reviewed and updated. EVIDENCE: 1. The record for resident 5, admitted to the facility on 06/05/2023, has documentation of home health plan of care, effective 06/28/2023 ? 08/26/2023, which indicates that this resident will be receiving physical therapy 1 time per week for 1 week, 2 times per week for 2 weeks, and 1 time per week for 5 weeks; and speech therapy 1 time per week for 1 week. The ISP for resident 5, dated 06/07/2023, did not contain documentation that physical therapy and speech therapy services are being provided. 2. The ISPs dated 07/09/2023 in the records for residents 1 and 3 are incomplete as they lacks documentation of the dates of identified needs, where services will be provided, the expected outcome/goal and date of expected outcome/goal.
Plan of Correction:	On 7.26.23 the Administrator contacted the home health care provider and requested Resident 5?s care plan. The care plan was added to Resident 5?s file. The Administrator added home health care as a service and need to Resident 5?s ISP. The Administrator and Staff 6 will retrain Nurse/RMA/DCS on how to add this service and need in RTasks and to a resident?s ISP in the Departmental meeting on 8.14.23. On 7.27.23 the Administrator emailed the development team with RTasks regarding the existing ISPs lacking the following information: dates of identified needs, where services will be provided, the expected outcome/goal and date of expected outcome/goal, and requested they customize the ISPs to mirror the VDSS Model Form. RTasks confirmed via email on 7.28.23 that they were working on the changes. The Administrator and Staff 6 met with the RTasks team on 8.2.23 to review the customized changes. Resident 1 and 3 ISP will be updated/amended on 8.15.23. The customize version mirrors the VDSS Model Form, so the ISP?s should be in compliance moving forward.
Standard #:	22VAC40-73-520-I
Description:	Based on observations of the facility physical plant and staff interview, the facility failed to post a monthly activity schedule. EVIDENCE: 1. A monthly activity for July 2023 was not posted in the facility on the day of inspection. Staff 6 expressed in an interview that the facility is working on their activities and the monthly schedule.
Plan of Correction:	On 7.28.23 the Administrator created the Activity Calendar for August. The activities calendar was posted on 8.1.23 by Staff 6. Staff 6 and the Administrator met with Staff 1 and the two other hired staff that are responsible for specific activities to review the Activities Calendar. The Administrator discussed The Activities Calendar with all staff during the 8.9.23 All Staff Meeting.
Standard #:	22VAC40-73-640-A
Description:	Based on observations of the facility medication carts, review of facility policies and staff interview, the facility failed to implement its medication management plan specifically regarding its methods to prevent the use of outdated, damaged, or contaminated medications, and its methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. 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 and the oncoming staff must sign off as a ?Witness? in RTasks. The administrator can also serve as a ?Witness? in RTasks of this process.? 2. The Control Sign Sheet for medication cart A, which became effective on July 5 per staff 2, was not completed by the following shifts on the following dates: On 07/05/2023, the outgoing evening shift and oncoming day shift did not sign; on 07/06, the oncoming evening shift did not sign; on 07/07, the outgoing evening shift and the oncoming evening shift did not sign; on 07/08, the outgoing evening shift did not sign; and on 07/26, the outgoing evening shift did not sign. 3. The facility?s current medication management plan states ?2.) The assigned RMA and/or Nurse will check medications on a weekly basis for outdated medications. 3.) Use Cheat Sheet for open and close dates for insulin. 4.) All outdated medications will be disposed of by the facility and new ones will be ordered to ensure that the resident will have his medications and the date will be current.? 4. A Novolog FlexPen prefilled syringe 100 units/mL with an open date of 06/07/2023 and a label to discard the medication after 28 days with an expiration date of 07/04/2023 was noted in the medication cart on the day of inspection.
Plan of Correction:	On 7.26.23 the Administrator informed Nurse/RMA?s of the Control Sign Sheet missing signatures. Nurse acknowledged it being her oversight. On 7.26.23 the Administrator added the daily chore (confirm signature for controlled sign sheet) to RTasks with detailed instructions for oncoming and outgoing shifts to remember to sign. On 7.26.23 the Administrator added a every other day chore (discard expired medications) to RTasks with detailed instructions for Nurse/RMA?s to safely discard/dispose of expired medications. The Administrator requested sticker labels from the pharmacy on 8.9.23 that include date open and date expired. The sticker labels were received on 8.10.23. The Nurse/RMA Department will have an in-service on 8.14.23 with Nurse Carrie Turner for retraining. The Medication Management Plan was reviewed in the staff meeting on 8.9.23.
Standard #:	22VAC40-73-650-E
Description:	Based on resident record review, the facility failed to ensure that signed physicians orders were maintained in resident records. EVIDENCE: 1. The record for residents 1, 2 and 3 did not contained signed physicians orders for all medications prescribed to the residents.
Plan of Correction:	The Administrator confirmed with the pharmacy on 7.28.23 that all signed physician orders are faxed to the facility. The Administrator discussed in the staff meeting on 8.9.23 the missing signed physician orders and reminded Nurse/RMA/DCS to scan and save all signed physician orders sent via fax from the pharmacy and/or provider, to the residents file in RTasks. Residents 2 and 3 signed physician orders were saved in their files on 8.9.23. The Administrator created an MD order from RTasks for Resident 1 and sent it to his provider on 8.11.23, via email, for the provider to review, sign, and return. The provider is scheduled to be onsite 8.17.23 and the Administrator will request the signed order if it has not been provided prior to the onsite visit. The Administrator will show the Nurse/RMA/DCS staff in the Departmental Meeting on 8.14.23, how to create an MD Order in RTasks for the orders to be sent with the residents on future doctor appointments, so the orders can be signed.
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. At 9:39am on the day of inspection a container of Sani Professional Disinfecting Multi-Surface wipes was observed sitting in an unlocked, bottom cabinet near the refrigerator in the dining room. 2. At 9:53am on the day of inspection a can of Champion Stainless Steel Cleaner was observed sitting out on the top of the cabinet next to the refrigerator in the dining room. No staff were present in the dining room at the time this cleaning agent was observed.
Plan of Correction:	Staff 6 secured the Sani Professional Disinfecting Multi-Surface wipes following the sate inspection on 7.26.23. Staff 6 discussed the violation with the Director of Dietary & Environmental Services on 7.26.23. The Administrator reviewed this violation and the standards of regulations during the All Staff meeting on 8.9.23. Staff 6 and The Administrator retrained on the Daily Facility Walk-Thru and reiterated the importance of cleaning supplies being attended to and then locked and secured. The Administrator reviewed the chore and detailed instructions on this task on 8.9.23.
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 keep clean. EVIDENCE: 1. The carpets in rooms 12, 28 and 31 were observed to have heavy stains on the day of inspection.
Plan of Correction:	The Administrator informed the outsourced cleaning service, on 8.9.23, of the heavy stains in room 12, 28, and 31. The Administrator requested the cleaning service to audit and inspect all rooms to determine the conditions of the carpet. We discussed keeping the carpet routinely cleaned (Mon ? Fri). The Administrator discussed with Staff 6 and The Director of Maintenance replacing all carpet in residents rooms throughout the next year, beginning with rooms 12, 28, and 31.