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: Jan. 4, 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/04/2023, 9:05am ? 3:12pm 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: 76 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 12 Number of staff records reviewed: 7 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: LI observed breakfast, lunch, activities calendar, med pass 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on observations of the facility medication cart, the facility failed to implement their infection control policy in regards to assisted blood glucose monitoring. EVIDENCE: 1. The facility infection control policy has documentation that each individual resident requiring blood glucose monitoring will have their own glucometer, which will be kept in their room with supplies for testing blood glucose. The LI observed a glucometer on the Unit 1&2 medication cart on the day of inspection. The glucometer was labeled as ?House Stock?. In an interview with staff 7 it was expressed that the glucometer was currently being used to test blood sugars for resident 12.
Plan of Correction:	The glucose monitor and container were labeled and placed in resident room the day of survey. The labels on both the containers and the meters will be maintained and kept in resident?s room. Nurses/RMAs will be educated on infection control policy related to blood glucose monitoring. The labels will be checked via the day and night shift daily task list to ensure compliance. [SIC]
Standard #:	22VAC40-73-440-D
Description:	Based on a review of resident records, the facility failed to ensure that private pay uniform assessment instruments (UAI) were completed as required. EVIDENCE: 1. The UAI?s dated 10/27/2022 for resident 6, 12/14/2022 for resident 7 and the UAI dated 11/23/2022 for resident 11 has documentation that medications are administered by professional nursing staff. These residents also receive medication administration from facility registered medication aides (RMAs) who are considered laypersons on the UAI form. 2. The UAIs for resident 2, dated 11/17/2022, resident 3, dated 09/28/2022, and resident 8, dated 08/30/2022, contained documentation that the residents? medications are administered/monitored by professional nursing staff; however, the facility employees registered medication aides (RMAs) to administer medications to residents and RMAs are not professional nursing staff.
Plan of Correction:	The UAIs were updated to layperson to reflect that RMAs administer medications the day of survey. The UAI paperwork cannot be recreated. However, the UAIs are now correct. The DON/designee will continue to perform the UAI assessment reflecting the correct selection related to medication administration. The QA Director/Designee will audit 10% of the UAIs for the next 3 months to ensure compliance. If compliance not met, audits will continue as needed. [SIC]
Standard #:	22VAC40-73-450-D
Description:	Based on a review of resident records, the facility failed to ensure that care and services provided by hospice were included on individualized service plans (ISP). EVIDENCE: 1. The ISP dated 08/25/2022 in the record for resident 11 has documentation of the identified need for hospice but the ISP does not include the specific care and services that hospice is providing to this resident.
Plan of Correction:	The individualized service plan was updated to reflect hospice care and services the day of survey. The individualized service plan cannot be recreated. However, the individualized service plan is now correct. The DON/designee will continue to complete the individualized service plan appropriately on hospice residents. The QA Director/Designee will audit 10% of hospice residents? individualized service plans for the next 3 months to ensure compliance. If compliance not met, audits will continue as needed. [SIC]
Standard #:	22VAC40-73-640-A
Description:	Based on observations of the facility medication cart, the facility failed to implement their medication management plan in regards to preventing the use of outdated medications. EVIDENCE: 1. The facility medication management plan has documentation that all vials, sprays, inhalers and insulin pens will be dated when opened and will be discarded according to pharmacy suggested expiration dates. A Tresiba Flextouch pen and a Novolog Flexpen were noted to be open and in the medication cart for resident 12. Both pens did not contain a date that they were opened to insure proper discarding per the manufacturers instructions.
Plan of Correction:	The insulin pens were dated the day of survey. All insulin pens will be dated when opened. Nurses/RMAs will be educated on dating medications when opened. Medication management plan signed by nurses/RMAs in January. The pens will be monitored on day and night shift to ensure pens are dated when opened. The QA Director/Designee will perform monthly cart audit for 3 months to ensure compliance. If compliance not met, audits will continue as needed. [SIC]
Standard #:	22VAC40-73-650-E
Description:	Based on a review of resident records, the facility failed to ensure that physician orders were maintained in resident records. EVIDENCE: 1. During the morning medication pass conducted on 01/04/2023, the LI observed a cotton type dressing covered with ace wraps on both legs for resident 7. Interview with staff 6 expressed that resident 7 is receiving this treatment through physical therapy services. The physician order for leg wraps to both of resident 7?s legs was not located in the residents record on the day of inspection.
Plan of Correction:	The physician order was placed in resident record the day of survey. Nurses, RMAs and therapists will be educated on maintaining resident records, to include but not limited to orders. The DON/designee will review resident records for completeness related to therapy services. The QA Director/Designee will audit 10% of resident records from therapy for three months. If compliance not met, audits will continue as needed. [SIC]
Standard #:	22VAC40-73-680-C
Description:	Based on observations of the facility morning medication administration pass conducted on 01/04/2023, the facility failed to ensure that medications were administered no later than one hour after the facility standard dosing schedule. EVIDENCE: 1. Resident 5?s prescribed 8:00am medications Lexapro 5mg and Exelon 4.5mg were observed to be administered at 9:32am on the day of inspection. 2. Resident 6?s prescribed 8:00am medications Brovana Nebulizer, Pulmocort Inhaler, Zyrtec 10mg and Cozaar 10mg were observed to be administered at 9:39am on the day of inspection.
Plan of Correction:	Medication error documentation was completed. The medication error cannot be corrected. However, the medication times were changed to more appropriate times the day of survey. Nurses/RMAs will be educated on ensuring medication times are followed and the practice of changing medication times as appropriate. Medication pass audits of 10% of nurses/RMAs will be completed by the DON/designee monthly for 3 months to ensure compliance. If compliance not met, audits will continue as needed. [SIC]
Standard #:	22VAC40-73-680-G
Description:	Based on observations of the facility medication carts, the facility failed to ensure that over the counter medications were labeled with residents names. EVIDENCE: 1. The Unit 1&2 medication cart contained a bottle of Focus Select, Amazing Formula Iron, Swanson Full Spectrum Turmeric, Spring Valley Glucosamine/Chondroitin, Spring Valley Calcium 600mg, Nature Made Vitamin D3, Spring Valley Omega-3 500mg and Preservation AREDS in the medication cart. These over the counter medications were not labeled with a residents name at the time of the inspection.
Plan of Correction:	The over the counter medications were labeled with resident names the day of survey. The names on over the counter medications will be maintained. Nurses will be educated on proper maintaining of resident names on over the counter medications. Over the counter medications will be monitored day and night shift to ensure names are in place on all over the counter medications. The QA Director/Designee will perform monthly cart audit for 3 months to ensure compliance. If compliance not met, audits will continue as needed. [SIC]
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the building, the facility failed to ensure cleaning supplies were stored in a locked area. EVIDENCE: 1. At approximately 9:47AM, one licensing inspector (LI) noted that the door to the third floor laundry room was unlocked and unattended. The LI observed a spray bottle of Kroger laundry stain remover and a container of Tide free and gentle laundry detergent located under the sink in an unlocked cabinet. At 9:57AM, the LI noted that the door to the laundry room was still unlocked and unattended.
Plan of Correction:	The cleaning supplies were removed the day of survey. Showalter staff will be educated that cleaning supplies cannot be left in unsecured areas. Residents and their families will be informed by Social Worker that they cannot leave cleaning supplies in unsecure areas. Housekeeping/laundry staff will round daily to ensure no supplies are left. The QA Director/Designee will perform monthly laundry room audits for 3 months to ensure compliance. If compliance not met, audits will continue as needed. [SIC]