VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Highland House
3501 Longdale Furnace Road
Clifton forge, VA 24422
(540) 862-4271

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Sept. 14, 2021

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Technical Assistance:

To ensure that the facility had a thorough understanding of the standards, the licensing inspector had a discussion with the Administrator as well as the Administrator from the facility owned by the same corporation regarding standards 120-A, 210-D, 450-C, 490-B, and 1030-B.

Comments:

A renewal inspection was initiated on 09/14/2021 and concluded on 09/16/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 14. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 2 resident records, 2 staff records, activities calendar for the current month, staff schedule for the past two weeks, recent health care oversight, recent fire inspection, dates/times of the past year's fire drills, recent dietitian review, and recent pharmacy review submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 09/16/2021. An exit interview was conducted with the Administrator as well as an Administrator from an assisted living facility that is owned by the same corporation on 09/16/2021, 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. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-290-B
Description:	Based on observation, the facility failed to post the name of the current on-site person in charge. EVIDENCE: 1. When the licensing inspector arrived at the facility on 09/16/2021 for the on-site inspection, there was no posting indicating the name of the current on-site person in charge.
Plan of Correction:	-Corrected during inspection - Person-In-Charge will be updated as part of the changeover each shift to ensure that it stays up to date with who is in charge during each shift. - This will be monitored daily by the Administrator.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure that physical examinations were completed as required prior to a resident's admission. EVIDENCE: 1. The "Admission/Retention Report Of Physical Examination" for resident 1, dated 02/11/2021, did not contain whether or not the resident is or is not capable of self-administering medication.
Plan of Correction:	-Corrected by Physician on 9/17/2021 - History and Physicals will be reviewed by the AIT and then the LPN will follow up and review to ensure that all needed documentation is there.
Standard #:	22VAC40-73-640-A
Description:	Based on document review, the facility failed to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility's current medication management plan, "American Retirement Homes, Inc. Highland House Medication Management Plan" states "An assigned Licensed Nurse/Registered Medication Aide will begin a shift by completing a controlled drug count." and "Two Licensed Nurse/Registered Medication Aides will do the count of each controlled drug, one accounting for the actual number/amount of the drug, the other verifying the number/amount recorded as being available on the control sheet. A control drug count sheet is to be signed by individual going off duty, and the one accepting the responsibility for the control drugs, and medication administration." 2. The "Controlled Drugs - Count Record" for August 2021 and September 2021 does not contain the signatures of the medication staff for the following dates: "RMA OFF (11-7)" - 08/01/2021, 08/08/2021, 08/10/2021, 08/16/2021, 08/28-29/2021, 09/01/2021 and 09/03/2021; "RMA ON (7-3)" - 08/12/2021, 08/19-20/2021, 08/25-26/2021, 08/31/2021, 09/02/2021, and 09/05/2021; "RMA OFF (7-3)" - 08/12/2021, 08/19-20/2021, 08/25-26/2021, 08/31/2021, 09/02/2021, and 09/13/2021; "RMA ON (3-11)" - 08/07/2021, 08/12/2021, 08/14/2021, 08/26/2021, 08/28/2021, 08/31/2021, 09/02/2021, 09/08/2021, and 09/13/2021; "RMA OFF (3-11)" - 08/07/2021, 08/09/2021, 08/15/2021, 08/26-27/2021, 08/31/2021, 09/01-02/2021, 09/08/2021, and 09/15/2021; and "RMA ON (11-7)" - 08/07/2021, 08/09/2021, 08/15/2021, 08/28/2021, 09/02/2021, and 09/15/2021.
Plan of Correction:	- Staff will have training on the proper way to document and sign the Control Drug Count Record on 9/23/2021. Also a new Control Drug Count Record has been implemented for easier understanding.
Standard #:	22VAC40-73-680-H
Description:	Based on resident record review, observation, and staff interview, the facility failed to ensure that at the time a medication is administered, the facility documented on a medication administration record (MAR) all medications administered to residents. EVIDENCE: 1. The record for resident 1 contained a signed physician's order, dated 09/01/2021, for "Imodium 2 mg PO X 1 Dose DX: Diarrhea". Interview with staff 4 revealed that she did administer the medication to resident 1; however, she did not document it on a MAR.
Plan of Correction:	-LPN was trained to put Temporary Orders on the MARs. -All Future Orders will be sent to pharmacy, as well as documented on the MARs -A copy of all orders will be placed in a folder and kept for a week, and each Monday the AIT/LPN will review
Standard #:	22VAC40-73-680-M
Description:	Based on resident record review, observation, and staff interview, the facility failed to ensure medications ordered for PRN (as needed) administration were available. EVIDENCE: 1. The record for resident 1 contained a signed physician's order, dated 04/23/2021, for "Acetaminophen 325 MG Tablet take two tablets (=650MG) by mouth every 4 hours as needed for pain" and "Zinc Oxide 20% Ointment apply topically every day as needed for protection". These two medications were not observed in the medication cart during medication cart/storage audit on 09/16/2021. Staff 4 confirmed that the aforementioned PRN medications were not onsite and available.
Plan of Correction:	- Corrected. Family Brought medications in on 9/16/2021. Medications were labeled and put in the Medication Cart. -AIT and LPN will work with family to ensure medications are in the building earlier, so medications can be sent to pharmacy for repackaging.
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to ensure a valid physician's order for oxygen contained all the required components. EVIDENCE: 1. The record for resident 2 contains a physician's order , dated 04/23/2021, that showed "Administer nocturnal ocygen at 2L/PM via nasal canula and during the day as needed/tolerated for COPD". The order does not contain the oxygen source.
Plan of Correction:	- Physician corrected order on 9/15/2021 -Spoke with Physician regarding how orders need to be written. AIT and LPN will review all orders to ensure accuracy.
Standard #:	22VAC40-73-870-A
Description:	Based on observation during on-site inspection, the facility failed to ensure that the interior and exterior of the building is maintained in good repair and kept clean. EVIDENCE: 1. During on-site inspection on 09/16/2021, the driveway in front of the facility had several, small potholes and had several areas of broken asphalt. The hallway of the West Wing was sticky starting from the entrance of the hallway from the common area of the facility until half way down the hallway. The carpet in the rooms of resident 2 and 3 had several stained areas throughout both rooms. The grout between the tiles on the floor around the toilet and the caulk around the bottom of the toilet in resident 4's bathroom was stained.
Plan of Correction:	- Holes in driveway will be repaired by 10/16/2021 -The sticky floor was cleaned while inspector was on-site. Staff will monitor the floors to ensure they are clean. -Carpet in Resident #2 and Resident #3 rooms will be replaced - Resident #4 will put new laminated flooring down in restroom. Caulking around toilet has been corrected.