VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Fairview Home
5140 Hatcher Road
Dublin, VA 24084
(540) 674-5260

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: June 9, 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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 06/09/2023, 9:55am to 2:36pm 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: 46 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: 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 #:	22VAC40-73-440-K
Description:	Based on a review of resident records, the facility failed to ensure that the uniform assessment instrument (UAI) is completed as required by 22VAC30-110-B-2. EVIDENCE: 1. The UAI in the record for resident #3, dated 12/14/2022, identifies disoriented ? some spheres, some of the time, regarding orientation. The section regarding the spheres affected was found to be blank. 2. The UAI in the record for resident #6, dated 02/14/2023, identifies disoriented ? some spheres, some of the time, regarding orientation. The section regarding the spheres affected was found to be blank. 3. The UAI in the record for resident #7, dated 02/26/2023, identifies disoriented ? some spheres, some of the time, regarding orientation. The section regarding the spheres affected was found to be blank.
Plan of Correction:	Administrator or Designee will review UAI?s for any incomplete areas when received from the qualified assessor and will return them to the qualified assessor for completion or correction if needed to ensure completed UAI?s are on file. [SIC]
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to address all identified needs on the Individualized Service Plan (ISP) for one of the eight resident files that were reviewed. EVIDENCE: 1. The UAI in the record for resident #8, dated 12/29/2022, identifies disoriented ? some spheres, some of the time, regarding orientation. The ISP in the record for resident #8, dated 01/06/2023, does not address these needs.
Plan of Correction:	Administrator or Designee will assure all needs identified in the UAI are addressed in the ISP. [SIC]
Standard #:	22VAC40-73-610-B
Description:	Based on observations made during the tour of the building, the facility failed to record menu substitutions or additions on the posted menu. EVIDENCE: 1. During the day of the inspection the LI observed the menu for 06/09/2023 to serve homemade ravioli, California mixed vegetables, and fruit. 2. When the LI observed lunch being served to the residents, they had tuna salad sandwiches, potato salad and crackers.
Plan of Correction:	The Food Services supervisor will review with all dietary staff the regulations pertaining to food services and will assure menu changes as they are made. [SIC]
Standard #:	22VAC40-73-640-A
Description:	Based on observations made during the medication cart audit and the noon medication pass, the facility failed to document that all controlled substances where accurately counted when the assigned medication administration staff changes. EVIDENCE: 1. On June 2, 2023, the ?Sign off sheet for Controlled Meds? was not signed by the first shift staff member.
Plan of Correction:	Administrator will provide education/reminders to medication administration staff regarding methods to ensure document of accurate counts of controlled substances at shift changes. Nursing Department supervisors will monitor for ongoing compliance. [SIC]
Standard #:	22VAC40-73-660-A-7
Description:	Based on observations made during the medication cart audit, the facility failed to properly label single-use and dedicated medical supplies. EVIDENCE: 1. The glucometer for resident #9 was labeled but the bag for the glucometer was not. 2. The glucometer for resident #10 was labeled but the bag for the glucometer was not.
Plan of Correction:	Administrator will provide education/?reminders to medication administration staff regarding proper labeling for dedicated medical supplies upon receipt and Nursing Dept supervisors will monitor for compliance. [SIC]
Standard #:	22VAC40-73-700-1
Description:	Based on a review of resident records, the facility failed to ensure the physician's or other prescriber's order included all necessary components. EVIDENCE: 1. The physician?s orders as of 05/24/2023 for resident #4 include an order for oxygen. 2. The order states the following: Oxygen, can wear O2 during the day as needed to maintain safe O2 stats. 3. The order did not include the oxygen source, such as compressed gas or concentrator, the delivery service, such as nasal cannula, reservoir nasal cannulas, or masks, or the flow rate determined therapeutic for the resident.
Plan of Correction:	Administrator provided education/reminders to medication administration staff for all the necessary components for oxygen orders. Medication administration staff will QA upon receipt of all oxygen orders and QA staff will monitor compliance for all oxygen orders monthly. [SIC]
Standard #:	22VAC40-73-860-G
Description:	Based on observations made during the tour of the building, the facility failed to ensure that all hot water available to residents shall be maintained within a range of 105 degrees Fahrenheit to 120 degrees Fahrenheit. EVIDENCE: 1. In the hallway across from the dining room entrance is a water and ice station available to staff and residents. 2. There is an instant hot water machine also available. When the LI tested the water temperature it registered 172.8 degrees Fahrenheit.
Plan of Correction:	Administrator or Designee will assure all hot water available to residents are maintained in the required temperature range and will monitor temperatures monthly. Hot water machine was removed 6/12/23. [SIC]