VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Blake at Charlottesville
250 Nichols Court
Charlottesville, VA 22901
(434) 973-7900

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: March 20, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3-20-24 from 9:05 a.m.-12:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 3-7-24 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 115 Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on a review of the resident?s record the facility failed to ensure that the fall risk rating shall be reviewed and updated under each of the following circumstances: 1. At least annually; 2. When the condition of the resident changes; and 3. After a fall. Evidence: The record for Resident #1 contained charting notes that documented that the resident went to the ER due to a fall on February 10, 2024. However, the resident?s record did not contain a fall risk assessment/rating after that fall.
Plan of Correction:	The Facility will ensure that all fall risk ratings are completed after each fall and at least annually. The Director of Wellness (and/or designee) will verify that the fall risk ratings are completed in a timely manner. The Executive Director will spot check during the monthly safety meeting to ensure compliance for three consecutive months.
Standard #:	22VAC40-73-450-H
Complaint related:	Yes
Description:	Based on a review of the resident?s record the facility failed to ensure that the facility shall ensure that the care and services specified in the individualized service plan (ISP) are provided to each resident. Evidence: -The ISP for Resident # 1 dated 12-8-23 listed Bathing and Showering Assistance frequency as ?Once every Monday, Thursday, and as needed.? However, the facility?s Task Administration Record for January 2024 and February 2024 failed to document this frequency for resident?s bathing and showering. -The ISP for Resident # 1 dated 12-8-23 listed Toileting and Incontinence Care Assistance frequency as ?3 x every day and as needed.? However, the facility?s Task Administration Record for January 2024 and February 2024 failed to document this frequency for resident?s toileting and incontinence care. - The ISP for Resident # 1 dated 12-8-23 listed Dressing Assistance frequency as ?2 x every day?. However, the facility?s Task Administration Record for January 2024 and February 2024 failed to document this frequency for resident?s dressing assistance. - The ISP for Resident # 1 dated 12-8-23 listed Diet and Dietary Assistance frequency as ?As Needed Every Day.? However, the facility?s Task Administration Record for January 2024 and February 2024 failed to document this frequency for resident?s Diet and Dietary Assistance. - The ISP for Resident # 1 dated 12-8-23 listed Housekeeping and Laundry frequency as ?Once Every Monday And As Needed.? However, the facility?s Task Administration Record for January 2024 and February 2024 contained no documentation at all to indicate Housekeeping and Laundry for resident.
Plan of Correction:	The Facility shall ensure that personal assistance and care are provided to each resident as necessary and documented appropriately. All direct care staff are being reeducated on daily charting of each resident?s ADL?s tasks. However, housekeeping does not document in the Electronic Health Record tasks. They maintain their own tracking system. The Charge Nurse will ensure that care is provided to the residents and documented as per the above. The Director of Wellness (and / or an appropriate designee) will monitor daily charting and follow up as necessary. The Executive Director will spot check the above-described efforts and tasks daily for three consecutive months. The Executive Director will also verity that all housekeeping tasks are completed and documented for three consecutive months
Standard #:	22VAC40-73-460-F
Complaint related:	Yes
Description:	Based on a review of the resident?s record the facility failed to ensure that the facility shall notify the next of kin, legal representative, designated contact person, or, if applicable, any responsible social agency of any incident of a resident falling or wandering from the premises, whether or not it results in injury. This notification shall occur as soon as possible but no later than 24 hours from the time of initial discovery or knowledge of the incident. The resident's record shall include documentation of the notification, including date, time, caller, and person or agency notified. Evidence: The record for Resident # 1 contained charting notes dated February 10, 2024 stating, ?Resident returned from ED at UVA...no injuries found from fall.? However, the resident?s record contained no documentation of notification to the resident?s next of kin, legal representative, or designated contact person regarding the resident?s fall.
Plan of Correction:	The Facility will re-educate all nurses on family notification after an adverse incident and documentation. The Director of Wellness (and/or designee) will ensure that all nurses are educated and monitor to ensure adherence to said requirement. The Executive Director will spot check to ensure compliance.
Standard #:	22VAC40-73-460-H
Complaint related:	Yes
Description:	Based on a review of the resident?s record the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with: 1.The activities of daily living, to include Bathing - at least twice a week, but more often if needed or desired, Toileting, Eating/feeding 2. The instrumental activities of daily living, to include Meal Preparation, Housekeeping/Laundry 3.Ambulation, 4. Hygiene and grooming. Evidence: -The facility?s Shower Form for Resident # 1 only contained documentation with staff initials for resident shower dates for January 2024 for January 24 and 30 and for February 2024 for February 1, 8, 14, and 21. - There was no documentation/staff initials on the facility?s Task Administration Record for Resident # 1 for Bathing Assistance for January 2024 except for the following dates: January 15,18, and 25. - There was no documentation/staff initials on the facility?s Task Administration Record for Resident # 1 for Bathing Assistance for February 2024 except for the following dates: February 1 and 22. - There was no documentation/staff initials on the facility?s Task Administration Record for Resident # 1 for Dressing Assistance for ?Wake Up? except for the following dates in February 2024: February 1,5, 7,17. -There was no documentation/staff initials on the facility?s Task Administration Record for Resident # 1 for Dressing Assistance for ?Bed Time? except for the following dates in February 2024: February 6 and 14. - There was no documentation/staff initials on the facility?s Task Administration Record for Resident # 1 for Toileting/Incontinence Care Assistance except for the following dates in January 2024: January 1,7-9,13,14,18, 20, 21, 22, 24-26, and 29. - There was no documentation/staff initials on the facility?s Task Administration Record for Resident # 1 for Toileting/Incontinence Care Assistance except for the following dates in February 2024: February 1,4-9, 12,14,17,24, and 27. - There was no documentation/staff initials on the facility?s Task Administration Record for Resident # 1 for Meal Escort Assistance except for the following dates in January 2024: Breakfast-January 3, 9,15,18,19, 21,24, 25, 27, and 30. Lunch- January 2, 9,15, 21,24, and 25. Dinner-January 2, 9, 14, 24-26, and 30.
Plan of Correction:	The Facility shall ensure that personal assistance and care are provided to each resident as necessary, so the needs of the resident are met, all per the ISPs. All direct care staff are being reeducated on daily charting of each resident?s ADL?s tasks. The Charge Nurse will ensure that care is provided to the residents and documented per ISPs. The Director of Wellness (and / or an appropriate designee) will monitor daily charting and follow up as necessary. The Executive Director will spot check the above-described efforts and tasks daily for three consecutive months.
Standard #:	22VAC40-73-590-A
Complaint related:	Yes
Description:	Based on a review of the resident?s record the facility failed to ensure that at least three well-balanced meals, served at regular intervals, shall be provided daily to each resident, unless contraindicated as documented by the attending physician in the resident's record or as provided for in 22VAC40-73-580 G. Evidence: -There was no documentation/staff initials on the facility?s Task Administration Record for Resident # 1 for meal intake for Breakfast in February 2024, except on February 7,17, and 18. - There was no documentation/staff initials on the facility?s Task Administration Record for Resident # 1 for meal intake for Lunch in February 2024, except on February 7 and 17. - There was no documentation/staff initials on the facility?s Task Administration Record for Resident # 1 for meal intake for Dinner in February 2024, except on February 6, 14, and 22. - There was no documentation/staff initials on the facility?s Task Administration Record for Resident # 1 for meal intake for Breakfast in January 2024, except on January 3, 9,15,18,19, 21, 24 ,25, 27, and 30. - There was no documentation/staff initials on the facility?s Task Administration Record for Resident # 1 for meal intake for Lunch in January 2024, except on January 2, 9,15, 21, 24, and 25. - There was no documentation/staff initials on the facility?s Task Administration Record for Resident # 1 for meal intake for Dinner in January 2024, except on January 2,9,14, 24-26, and 30.
Plan of Correction:	The Facility will continue to provide three nutritional meals for all residents. Direct care staff to round and ensure all residents are escorted (as needed) to the dining room and that meal attendance is documented, as appropriate. Charge nurses to ensure that residents have had their meals and care staff have documented meal attendance as required by individual service plans. The Wellness Director (and/or designee) will review on daily basis to ensure compliance. The Executive Director will sample five (5) resident charts to ensure documentation is completed per above. Will repeat for 90 days.
Standard #:	22VAC40-73-930-D
Complaint related:	Yes
Description:	Based on a review of the resident record the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, the following shall be met: The facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. The documentation shall be retained for two years. Evidence: The record for Resident # 1 did not contain documentation of rounds. Staff # 1 was unable to locate rounds documentation for Resident # 1.
Plan of Correction:	The Facility will re-educate all direct care staff on rounding and care documentation. The Director of Wellness (and/or a designee) will ensure that rounding documentation is reviewed daily and prior to care staff shift changes. For a period of 90 days, the Executive Director will also make a monthly review of rounding documentation of at least five (5) residents to ensure compliance.