VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harpers Station Yorktown
4501 Victory Boulevard
Yorktown, VA 23693
(757) 798-8739

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Sept. 21, 2024

Complaint Related: No

Areas Reviewed:

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring An on-site monitoring inspection conducted on 10-21-24. Ar 07:30 a.m./ Dep 16:25 p.m. 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: 12 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 5 Observations by licensing inspector: Breakfast meal, emergency preparedness supply, first aid kit, water temperature Additional Comments/Discussion: 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on observation and staff interviewed, the facility failed to ensure blood glucose monitoring practices that are consistent with CDC recommendations were followed. Evidence: 1. On 10-21-24 during the medication pass observation with staff #3, resident #2?s blood glucose instrument (glucometer) was not labeled as required. 2. Staff #1 and #3 acknowledged the resident?s blood glucose instrument (glucometer) was not labeled.
Plan of Correction:	To ensure consistency with CDC recommendations. All glucose instruments will be labeled as required. Clinical staff meeting to be conducted regarding proper labeling of instruments. This will be audited monthly during clinical internal quality assurance check. Date to be completed by: 10/21/2024
Standard #:	22VAC40-73-40-B-10
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure that any document required by the standard to be posted was in at least 12-point type or equivalent size, unless otherwise specified. Evidence: 1. On 10-21-24, the facility assisted living activities calendar posted on the bulletin board located near the mailboxes was observed to be in less than 12-point type. 2. Staff #1 acknowledged the posted schedule?s font was not at least 12-point type.
Plan of Correction:	Administrator and Activites Director will ensure that the activites calendar posted on the bulletin board located near mailboxes and all other areas of the facility will be at- least 12-point type. New Calendars will be printed in 12-point type to replace the calendar posted with less than 12-point type. This will be reviewed with Administrator prior to putting calendars out to residents monthly. Calendar with corrected size to be attached. Date to be completed by: 11/1/2024
Standard #:	22VAC40-73-290-A
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure that facility written work schedule included the names, and job classification of all staff working each shift, with an indication of whomever is in charge at any given time. Evidence: 1. On 10-21-24, the management, maintenance, dietary, activity schedule neither the clinical schedule indicated whoever is in charge at any given time. The management, maintenance, dietary, and activity schedules did not include the names of the staff person. The activity calendar provided did not include the job classification of the staff noted. 2. Staff #1 and #2 acknowledged the written schedules provided did not include all of the required information.
Plan of Correction:	The facility will ensure that facility written work schedules include the names, and job classifications of all staff working each shift and indication of whoever is in charge at any given time. The person in charge will be notated on the maintenance, Management, dietary, and activities schedule. The names of the staff will be notated on the management, maintenance, dietary, and the activities schedule. The activities calendar will provide the job classification of the staff member noted. Each corrected staff scheduled attached. Date to be completed by: 11/5/24
Standard #:	22VAC40-73-410-A
Description:	Based on record reviewed and staff interviewed, the facility failed to have documentation acknowledging having received orientation to the facility for two of three records reviewed. Evidence: 1. On 10-21-24, resident #2?s record did not have documentation of having received orientation to the facility. The resident?s date of admit noted as 10-1-24. 2. Resident #3?s record did not have documentation of having received orientation to the facility. The resident?s date of admit noted as 9-28-24. 3. Staff #1 and #2 acknowledged residents #2 and #3?s record did not have documentation of acknowledgement of receiving orientation to the facility.
Plan of Correction:	The facility will ensure to obtain documentation acknowledging having received orientation to the facility. Records will be reviewed and documentation will be obtained regarding acknowledgement of orientation to facility. Resident orientation checklist completed and attached. Date to be completed by: 11/8/24
Standard #:	22VAC40-73-450-A
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included the assessed needs for three of three records reviewed. Evidence: 1. On 10-21-24, resident record review with staff #2, resident #1?s uniform assessment instrument (UAI) dated 10-3-24 noted transferring need assessed as mechanical help/physical assistance. The individualized service plan (ISP) dated 10-15-24 noted mechanical help/supervision. ?resident will need assistance of grab bars and wheelchair?staff will provide supervision with bathing. Staff will report any changes in their physical needs to the person in charge?. Resident?s eating need assessed as independent. The ISP noted, ?staff will provide reminders of all meals and supervision during mealtimes?. Wheeling need assessed as mechanical help. The ISP noted wheeling as mechanical and supervision. ?resident needs supervision with transferring into wheelchair. Staff will monitor to ensure resident is propelling wheelchair safely, locked brakes and getting assistance with transferring?. 2. Resident #2?s UAI dated 9-6-24 noted stairclimbing need assessed as mechanical help/supervision. The ISP dated 10-1-24 (10-6-24) noted stairclimbing as mechanical help/physical assistance. ?Resident will need handrails and physical assistance to perform stairclimbing safely?. Staff #2 made written change to ISP prior to the inspector taking a photograph of the ISP document. 3. Resident #3?s UAI dated 9-10-24 noted bathing need assessed as mechanical help/physical assistance. The ISP dated 10-10-24 noted ?bathing needs help, yes Mechanical & Human Help Supervision. Resident requires the use of shower chair and grab bars for bathing. Care staff will set up showers, and provide supervision for bathing while encouraging to participate to the highest level of independence?. 4. Staff #2 acknowledged the residents? assessed needs and care plan were not in agreement.
Plan of Correction:	Facility will ensure individualized service plans include the assessed needs. Records will be reviewed including UAI. Level of assistance will be audited and checked for accuracy and corrected if need be. Residents needs and care plan will be in agreement. Corrected ISP attached. ISPs are audited and documented for accuracy on a monthly basis during facilities internal quality assurance check. Date to be completed by: 11/15/24 and Ongoing
Standard #:	22VAC40-73-610-B
Description:	Based on observation and staff interviewed, the facility failed to ensure the menu for meals and snacks for the current week was dated and posted in an area conspicuous to residents. Evidence: 1. On 10-21-24, the facility?s menu for meals and snacks for the current week was not posted in the facility. 2. Staff #1 acknowledged the posted menu and snack for the current week was not posted in the facility on the morning of 10-21-24.
Plan of Correction:	Facility will ensure that the menu for meals and snacks for current week was dated and posted in a conspicuous area. Residents will be able to view daily. A menu for meals and snacks will be posted. Date to be completed by: 10/21/24
Standard #:	22VAC40-73-610-E
Description:	Based on staff interviewed, the facility failed to ensure a copy of a diet manual containing acceptable practices and standards for nutrition was kept current and readily available to personnel responsible for food preparation. Evidence: 1. On 10-21-24, during a tour of the kitchen with staff #1, staff #6 was not able to provide the inspector a copy of the diet manual. 2. Staff #1 and #6 acknowledged the facility did not have a copy of the diet manual as required.
Plan of Correction:	A list of acceptable diets are located in the director of resident services manual. The facility will ensure that a copy of this and standards for nutrition is kept and readily available to personnel responsible for food preparation. Will ensure acknowledgement and understanding of acceptable practices and standards are understood. Dietary Manual attached, acceptable diets attached. Date to be completed by: 11/8/24
Standard #:	22VAC40-73-680-M
Description:	Based on record reviewed, staff interviewed and observation, the facility failed to ensure that medications ordered for PRN administration was available, properly labeled for the specific resident, and properly stored at the facility. Evidence: 1. On 10-21-24 during the medication pass observation with staff #3, resident #1?s October medication administration record (MAR) noted resident prescribed Miconazole Nitrate as needed, PRN. A check of the medication cart was conducted, and this specific PRN medication was not available in the facility. 2. Staff #2 and #3 acknowledged the resident?s PRN Miconazole Nitrate was not available in the facility.
Plan of Correction:	The facility will ensure that medications ordered for PR and administration are available at all times 2 residents. Medications will be properly labeled for specific resident. And properly stored at the facility. Community will ensure that medications are available at all times by communicating with families and residents prior to medication running out. Community will financially take responsibility of medications if there is a delay in regard to family or resident obtaining the medication from pharmacy. Cart audits are conducted on regular basis, and PRNS evaluated monthly on facilities quality assurance evaluation. Medications to be sent for refill several 5-7 days prior to running out to obtain medication prior to running out. Date to be completed by: 11/8/24 and On-Going