VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Barrington at Hioaks
350 Hioaks Road
Richmond, VA 23225
(804) 320-1412

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: April 29, 2024 and May 15, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date the licensing inspector was on-site at the facility for each day of the inspection: 4/29/24, 5/15/24 The Acknowledgement of Inspection form was emailed for each date of the inspection. A complaint was received by VDSS Division of Licensing on 4/11/24 regarding allegations in the areas of: Staffing and Supervision, Resident Care And Related Services Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Staffing and Supervision An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations ; area(s) of non-compliance with standard(s) or law were Resident Care and Related Services. : A violation notice was issued; any violation(s) not related to the complaints 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 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on a documentation review, the facility did not ensure that individualized service plans shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. Collateral contact # 1 and staff # 1 reported during interviews that resident # 1 eats his meals in his room. The individual service plan for resident # 1, reviewed on 4/29/24 and 5/15/24 state ?feed resident in dining room? and ?resident will eat meals in dining room?. 2. The Medication Review Report for resident # 1 document a Physician Order dated 2/16/24 that state ?Diet change to mechanical soft liquids with moisture added to ALL SOILDS(gravy, sauce, condiments, etc.). The change in diet is not included on the resident?s individualized service plan reviewed on 4/29/24 at the facility. 3. The service plan documents a need for eating/feeding initiated 6/29/23 with no goal or interventions.
Plan of Correction:	1. Designee/DCS to complete 100% Diet Audit of AL/MC residents. 2. Designee/DCS will audit ISP and update. DCS/ED to educate clinical nursing team on policy for resident Diets. 3. Designee/DCS to complete weekly audit of new diet orders for compliance weekly x1 month, then monthly x2 month. (Total 3 months)
Standard #:	22VAC40-73-460-A
Complaint related:	No
Description:	Based on interviews and a review of file documentation, the facility did not ensure that the facility assume general responsibility for the health, safety, and well-being of the residents. Evidence: 1. The facility documented a weight loss of 26.5 lbs. over a 6-month period (September 2023 to March 2024). 2. Resident # 1 was admitted to the hospital on 4/3/24. 3. The hospital documented a diagnosis of failure to thrive and a weight of 40.909 kg (90 lbs.) which represents a 50% weight loss (181 lbs. to 90 lbs.). 4. Resident was discharged from the hospital and placed in hospice at a skilled nursing facility.
Plan of Correction:	1. Designee/DCS to complete 100% Diet Audit of AL/MC residents. 2. Designee/DCS will audit ISP and update. DCS/ED to educate clinical nursing team on policy for resident Diets. 3. Designee/DCS to complete weekly audit of new diet orders for compliance weekly x1 month, then monthly x2 month. (Total 3 months)
Standard #:	22VAC40-73-580-B
Complaint related:	No
Description:	Based on interviews and a review of documentation, the facility did not ensure that all meals shall be served in the dining area as designated by the facility. Evidence: 1. Collateral contact # 1 stated during an interview on 4/16/24 that the resident was receiving meals in his room. 2. Staff # 1 confirmed during an interview on 4/29/2024 that meals were being served in the room. 3. No documentation was found to support that the resident should have the option of meals served in his room: (a) No written agreement found in the resident?s record that was signed and dated by both the resident or the resident?s responsible party and the licensee or administrator. 4. Supporting documentation was requested from staff # 1 by email on 4-30-24. No supporting documentation was provided.
Plan of Correction:	1. Designee/DCS will complete 100% Audit of residents with room service. 2. Designee/DCS will provide education to care team on resident rights to option of room service vs dining room. 3. Clinical Team/DCS will update the ISP to reflect preferences. 4. Weekly audits x1 month, then monthly x2, totaling 3 months. Noting residents during dinning to ensure attendance/offer dining room to make sure preference is honored.