VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Showalter Center
1060 Showalter Drive
Blacksburg, VA 24060
(540) 443-3427

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: March 15, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

The LI for Showalter Center, along with an additional inspector, conducted an unannounced monitoring inspection on 3/15/2022 from 9:45 AM until 3:45 PM, finding 80 residents in care. The inspection included a tour of the physical plant, observation of a medication pass, a review of the medication storage carts, staff/resident interviews, and observation of portions of the midday meal and craft activity. Ten resident records were thoroughly reviewed, and an additional five were partially reviewed in relation to the observation of the medication pass and/or special diets. Sworn disclosure statements and criminal record checks were examined for all newly hired staff, and the records of five staff were thoroughly examined. Additional facility documentation was surveyed for compliance with the Standards for Assisted Living Facilities. Findings were reviewed with facility staff during the inspection. An exit interview was conducted with the facility Administrator, the assistant Director of Nursing, and the facility Social Worker on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 309-5982.

Violations:

Standard #:	22VAC40-73-100-A
Description:	100-A Based on observation, the facility failed to implement its infection control program addressing the surveillance, prevention, and control of disease and infection that is consistent with the federal Centers for Disease Control and Prevention (CDC) guidelines and the federal Occupational Safety and Health Administration (OSHA) blood borne pathogens regulations. EVIDENCE: 1. The facility?s Infection Control Program, approved on 6/28/2018, states that ?7. All staff members will be oriented to proper hand washing technique at orientation, annual in-services, and frequent on the floor audits? 8. All staff and volunteers will be educated about the prevention and control of infection focusing on the spread of infection? Staff and volunteers will be reminded about good hand washing techniques, use of PPE, as well as other means of spreading infection through contact. Standard precautions and use of PPE will be stressed as the way to best prevent the spread of infections. Standard precautions will be monitored by education staff and managers with random competencies.? 2. While observing the noon medication pass, collateral 1 observed that staff 1 did not wash or sanitize her hands prior to medication administration nor did she wash or sanitize her hands in between administering medications to different residents.
Plan of Correction:	1. Staff #1 was re-educated as to proper hand-washing technique. Additional bottles of hand sanitizer have been added to the medication cart for ease of access. 2. The QA/Education Director will oversee/conduct random audits of the Showalter medication passes over the course of the next six months to ensure the facility's Infection Control Program is accurately being followed. These audits will total no less than 18 and will result in a compliance rate of no less than 90% or will be repeated for an additional three months. 3. Systematic changes are in place to ensure compliance to the Infection Control Program by: Continued oversight by the new Director of Nursing (to start April 2022), additional training, and new hire orientation on hand-washing. 4. The QA/Education Director will ensure this deficient practice does not reoccur.
Standard #:	22VAC40-73-490-A
Description:	490-A 2.(b.) Based on record review and staff interview, the facility failed to ensure that for residents who meet the criteria for assisted living care that a licensed health care professional who is on site on a full-time basis, practicing within the scope of his profession, shall provide healthcare oversight at least every six months, or more often if needed, based on his professional judgment of the seriousness of a resident?s needs or stability of a resident?s condition. EVIDENCE: 1. Staff 7 stated that resident 11 is assessed as residential living level of care during the date of the inspection (03/15/2022); however, the uniform assessment instrument (UAI) for resident 11, dated 1/28/2022, indicated that resident 11 is assessed as assisted living level of care. 2. Resident 11 is prescribed the following medications on an as needed basis and they are documented as being able to be kept at resident?s bedside for self-administration: Biotene Dry Mouth Oral Rinse, swish and spit 15ml by mouth two times daily as needed for dry mouth; Docusate Sod Cap 100mg, one capsule by mouth two times a day as needed for constipation; Glycerin Supp (Adult) administer one suppository rectally one time a day as needed for constipation; Sinus Rinse Kit, administer one packet to both nostrils two times a day as needed for allergies. 3. None of the above mentioned medications were available to the resident in her room when the Licensing Inspector (LI) and staff 1 went in to compare the medications to the physician?s orders. Neither resident 11 nor staff 1 were able to locate these medications. 4. Resident 11 appeared to be confused when LI and staff 1 were asking her where these medications were, and she stated that she could not locate them and she wasn?t sure what the Biotene Oral Rinse was for. Resident 11 also appeared confused and did not understand what the prescribed Sinus Rinse Kit was when LI asked to see the Sinus Rinse Kit. 5. During the exit interview with staff 6 (Administrator) and staff 8 (DON), both stated that if residents in the facility are able to self-administer medications, then the facility does not provide health care oversight for those medications and it is not the facility?s responsibility to make sure that the medications are available to those residents.
Plan of Correction:	1. Resident #11 was reassessed and found to be in need of assistance with medication on 3/15/2022. 2. The QA/Education Director will conduct an audit of 100% of the residents who are deemed to be able to self-medicate and confirm the findings of the Showalter Center Director of Nursing. 3. Systematic changes are in place to ensure compliance to the monitoring of medication program by: The Director of Nursing has been demoted. A new Director of Nursing, a R.N., has been hired and has significant Long-Term care and Assisted Living experience working with medication management. The QA/Education Director will train her on the proper protocol for self-medication at orientation. 4. The Director of Nursing will ensure this deficient practice does no reoccur.