VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Babcock Manor, Inc.
State Route 691
Appomattox, VA 24522
(434) 352-8686

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: May 24, 2024

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 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

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: 05/24/2024 7:45am until 1:00pm 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: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 0-Not available for review. Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1040-A
Description:	Based on observations of the facility physical plant, the facility failed to ensure that a system of security monitoring was on all doors leading to the outside for monitoring of resident with serious cognitive impairments. EVIDENCE: 1. The 3 doors downstairs that lead to the outside were noted to have inoperable door alarms during the on-site inspection on 05/24/2024. The house houses a mixed population of residents such as resident 4, who has a diagnosis of dementia and is assessed with disorientation to some spheres some of the time with date and day being the spheres affected on the uniform assessment instrument completed on 12/17/2023.
Plan of Correction:	New batteries were placed in the door alarms on the day of inspection. The Administrator will in-service all staff on routine monitoring of all door alarms.
Standard #:	22VAC40-73-40-B
Description:	Based on observations and staff interviews, the licensee failed to ensure that at all times the department's representative is afforded reasonable opportunity to inspect all of the facility's buildings, books, and records as specified in ? 63.2-1706 of the Code of Virginia. EVIDENCE: 1. During the on-site inspection conducted on 05/24/2024, staff person 1, the designated person in charge, did not have access to staff records, staff and resident review of the emergency preparedness plan and staff review and practice of resident emergencies. This documentation was not available for the LI to review during the on-site inspection.
Plan of Correction:	The Administrator will speak with all staff persons in charge and develop a plan to ensure that they have access to all records when the Administrator is out of the building.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review, the facility failed to ensure that a uniform assessment instrument (UAI) was completed/updated whenever a significant change in a resident was observed. EVIDENCE: 1. The UAI dated 07/07/2023 in the record for resident 1 has documentation that the resident is independent with the ADLs for dressing, transferring, eating/feeding, walking, wheeling and mobility. Hospice notes dated 03/08/2023, 09/10/2023 and 12/09/2023 have documentation that resident 1 is dependent with these ADL needs. In an interview with staff person 1 on 05/24/2024, staff person 1 expressed that Hospice notes are correct and that the UAI has not been updated to reflect resident 1?s current ADL needs.
Plan of Correction:	The Administrator will have the UAI for resident 1 updated to reflect accurate ADL needs.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to ensure that Individualized service plans (ISP) were updated as needed for a significant change of a resident?s condition. EVIDENCE: 1. The record for resident 1 has documentation that the resident has an allergy to Latex, is receiving hospice services, is a high fall risk from the 07/07/2023 fall risk assessment and has documentation in hospice notes that a Geri Chair is used to prevent the resident from ambulating without assistance. The ISP dated 07/07/2023 in the record for resident 1 does not have documentation to address these identified needs or of any services being provided. 2. The record for resident 2 has documentation that the resident is receiving wound care through Hospice services and is a fall risk from the 04/11/2024 fall risk assessment. The ISP dated 08/06/2023 in the record for resident 2 does not have documentation to address these identified needs or of any services being provided. 3. The record for resident 3 has a physician order dated 10/03/2023 for the resident to be on a puree diet, a physician order dated 07/13/2024 for fall mats and a physician order dated 03/01/2024 for the resident to be in bad at all times. The record also has documentation that Hospice is providing wound care services for a wound to the residents coccyx and right heel. The ISP dated 12/17/2023 in the record for resident 3 does not have documentation to address these identified needs or of any services being provided.
Plan of Correction:	The Administrator will update resident ISPs to reflect all identified needs.
Standard #:	22VAC40-73-650-E
Description:	Based on resident record reviews, the facility failed to ensure that physician orders were maintained in resident records. EVIDENCE: 1. The record for resident 2 has documentation that the resident was admitted to Hospice services on 04/10/2024 and that Hospice is providing wound care services for a wound on the residents left ankle. In an interview with staff person 1 conducted on 05/24/2024, staff person 1 expressed that this is correct. The record for resident 2 does not have documentation of the physicians order for the treatment/wound care being provided to resident 2?s left ankle. 2. The record for resident 3 has documentation that the resicnet is receiving wound care services from Hospice from a wound on the residents coccyx and right heel. In an interview with staff person 1 conducted on 05/24/2024, staff person 1 expressed that this is correct. The record for resident 3 does not have documentation of the physicians order for the treatment/wound care being provided to resident 3?s coccyx and right heel.
Plan of Correction:	The Administrator has obtained physicians orders for these residents and will ensure that all physicians orders are in resident records.
Standard #:	22VAC40-73-690-B
Description:	Based on resident record review, the facility failed to ensure that residents assessed as assisted living level of care received a mediation review at least every 6 months. EVIDENCE: 1. The record for resident 2, assessed as assisted living level of care on their uniform assessment instrument dated 08/06/2023, has documentation that the last medication review was completed on 08/23/2023 for this resident. 2. The record for resident 3, assessed as assisted living level of care on their uniform assessment instrument dated 12/17/2023, has documentation that the last medication review was completed on 05/11/2023 for this resident.
Plan of Correction:	The Administrator will reach out to have a medication review completed for these residents.
Standard #:	22VAC40-73-710-C
Description:	Based on observations, resident record review and staff interviews, the facility failed to ensure that a physician's written order was obtained that specifies the condition, circumstances, and duration under which the restraint is to be used. EVIDENCE: 1. Resident 1 was observed by the LI at 8:09am on 05/24/2024 to be sitting in a Geri Chair with a tray that was secured over top. Documentation in Hospice notes dated 05/06/2024 has that ?During the day they sit her in a geri chair for her safety to prevent her from ambulating without assistance?. The record for resident 1 did not contain documentation of a physicians written order for the use of a Geri Chair with a secured tray that includes the condition, circumstances, and duration under which the restraint is to be used. In an interview with staff person 1 on 05/24/2024, staff person 1 confirmed they were not able to locate a physician order for the use of a Geri Chair in the record for resident 1.
Plan of Correction:	The Administrator has had the restraint discontinued for this resident.
Standard #:	22VAC40-73-710-D
Description:	Based on observations, resident record review and staff interviews, the facility failed to ensure that direct care staff kept a record of restraint usage, outcomes, checks, and any assistance required in subdivision 4 of this subsection and shall note any unusual occurrences or problems if any. EVIDENCE: 1. Resident 1 was observed by the LI at 8:09am on 05/24/2024 to be sitting in a Geri Chair with a tray that was secured over top. Documentation in Hospice notes dated 05/06/2024 has that ?During the day they sit her in a geri chair for her safety to prevent her from ambulating without assistance?. In an interview with staff person 1 on 05/24/2024, staff person 1 expressed that there was not documentation of a restraint record to include the usage, outcomes, checks or any assistance required for the Geri chair use for resident 1.
Plan of Correction:	The Administrator has had the restraint discontinued for this resident.
Standard #:	22VAC40-73-860-I
Description:	Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: 1. The laundry room located downstairs in the facility was observed to be unlocked at 8:13am on 05/24/2024. A bottle of Scrubbing Bubbles Mega Shower Foamer, a can of Favor Furniture Polish, a can of Comet with Bleach Cleaner, a bottle of Great Value Glass Cleaner, a bottle of Great Valus All Purpose Cleaner with Bleach and a bottle of First Choice Lavender Cleaner were observed sitting out on a table in the laundry room.
Plan of Correction:	The laundry room door was locked on the day of inspection. The Administrator will in-service all staff on the proper storage of cleaning supplies.
Standard #:	22VAC40-73-940-A
Description:	Based on observations of facility documentation, the facility failed to ensure compliance with the Statewide Fire Prevention Code (13VAC5-51) by ensuring a inspection by the appropriate fire official at least annually. EVIDENCE: 1. Facility documentation made available for review during the on-site inspection show that the last fire inspection was completed at the facility on 06/13/2022.
Plan of Correction:	The Administrator has made contact with the fire official and an inspection has been scheduled for the week on June 3, 2024