VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lakewood Manor Baptist Retirement Community
1900 Lauderdale Drive
Richmond, VA 23238
(804) 740-2900

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: Aug. 19, 2022

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

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: 8-19-22 from 9:48 a.m.- 4:45 p.m. 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: 61 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 Additional Comments/Discussion: The following items were reviewed/observed during the inspection: facility postings, facility documentation, criminal records checks, tour of the facility, first aid kit and emergency food/water supplies, medication pass/physician?s orders/Medication Administration Records (MARs). Residents and staff were also interviewed. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-F
Description:	Based on a review of staff records the facility failed to ensure that at least two hours of direct care staff annual training shall focus on infection control and prevention. Evidence: The training record for Staff # 1 (date of hire: 3-24-2009) contained only one hour of infection control and prevention training last dated 8-20-2021.
Plan of Correction:	a. Staff member #1 will complete 2 hours of infection control and prevention training by October 31, 2022, to include Infection Control and Prevention (1 hour), Infection Control ? Essential Principles (30 min) and Infection Control ? Isolating and Cohorting. b. All assisted living staff personnel files will be audited to ensure compliance with the necessary infection control and prevention training hours. Those staff members that do not have 2 hours of infection control education will complete the necessary hours by October 31, 2022. All new hires will receive the 2 hours of infection control training during their first week of hire and education on infection control will be conducted annually in the month of October. c. The Administrator of Assisted Living or designee will provide education to the Staff Development Coordinator and Human Resources Director on the requirements for all staff to obtain two hours of infection control and prevention training, annually. d. The Administrator of Assisted Living or designee will audit all new hire personnel files to ensure training is completed prior to resident care, once a week for 2 weeks, once a month for two months and once a quarter for two quarters. Audit results will be reviewed by the Administrator of Health Services and any areas of concern will be addressed.
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records the facility failed to ensure that each staff person shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: -The record for Staff # 3 (date of hire: 10- 3-2017) contained a TB screening last dated 5-20-21. -The record for Staff # 1 (date of hire: 3- 24-2009) contained a TB screening last dated 5-20-21. -The record for Staff # 4 (date of hire: 11- 3-2003) contained a TB screening last dated 6-21-21. -The administrator had staff to check the records for current TB screenings for Staff #3, #1, and #4, but no current documentation could be found.
Plan of Correction:	a. An audit of personnel files was completed and found that the risk screenings were often out of date or not documented. b. All staff with a missing or out of date screening form has been contacted and notified that the TB screening form must be completed no later than 10/14/2022 and returned to the Human Resources Director or Administrator of Assisted Living c. The Administrator of Assisted Living will educate the Human Resources Director on the requirements of Regulation 22VAC73-250-D in regard to TB screening. The Human Resources Director will audit personnel files to confirm all screening forms have been collected and are complete no later than 10/31/2022. The Human Resources Director will maintain a copy of records of TB screenings in her office in a secure binder annually for all team members effective 1/15/2023. d. The Human Resources Director or designee will audit files for annual TB screening/risk assessment once a week for two weeks, once a month for two months, and once a quarter for two quarters. Audit findings will be reported to the Administrator of Assisted Living and the Administrator of Health Services. Any areas of concern will be addressed.
Standard #:	22VAC40-73-440-A
Description:	Based on a review of resident records the facility failed to ensure that all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument (UAI) in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident?s condition. Evidence: The record for Resident # 6 (admit date: 8-2-22) contained a UAI (dated: 8-6-22) that was not completed prior to the resident?s admission.
Plan of Correction:	a. The UAI of Resident #6 has been reviewed and is accurate and up to date. b. An audit of all assisted living residents will be completed by the Nurse Manager to determine if the UAI was completed prior to their admission in order to determine if this was an isolated incident or if a process change is needed for admission c. The Administrator of Assisted Living or designee will educate all nurses who complete the UAI on the appropriate time frame of completion regarding new residents. d. The administrative nurse or designee will audit all newly admitted resident files once a week for two weeks, once a month for two months and once a quarter for two quarters to ensure that the UAI was completed prior to admission. Audit findings will be reported to the Administrator of Assisted Living and the Administrator of Health Services and any areas of concern will be addressed
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records the facility failed to ensure that the individualized service plan (ISP) contained a written description of what services will be provided to address all identified needs on the Uniform Assessment Instrument (UAI). Evidence: The ISP dated 8-2-2022 for Resident # 6 (admit date: 8-2-22) indicated ?No help needed? for the following activities: dressing, toileting, transferring, eating/feeding. However, the resident?s UAI (dated: 8-6-2022) indicates that resident ?Needs help? with those same activities.
Plan of Correction:	a. Resident #6?s ISP was revised to coincide with the resident?s UAI. The resident?s needs are reflected in the ISP and the ISP is up to date. b. Nurse Manager or designee will provide an audit of all residents? ISP?s and UAI?s to ensure that the ISP contains a written description of what services will be provided to address all identified needs on the UAI. c. The Administrator of Assisted Living will educate all nurses conducting ISP?s and UAI?s on the important of making sure that the information provided by both tools coincides with one another. d. The administrative nurse or designee will audit newly admitted residents UAI?s and ISP?s for consistency once a week for two weeks, once a month for two months, and once a quarter for two quarters. Audit findings will be reported to the Administrator of Assisted Living and the Administrator of Health Services. Any areas of concern will be addressed.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of resident records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual. Evidence of this review shall be the resident?s, his legal representative?s or responsible individual?s written acknowledgment of having been so informed, which shall include the date of review and shall be filed in the resident?s record. Evidence: The record for Resident # 8 (admit date: 7-28-2021) did not contain written acknowledgment of annual review of resident rights. Staff # 7 looked for it in the resident?s record but did not find it.
Plan of Correction:	a. Resident #8 was provided with a copy of rights and responsibilities by Medical Social Worker on October 5, 2022. Written acknowledgement was obtained and placed in the resident?s record on October 5, 2022. b. An audit of all resident files was completed on August 22, 2022 by the Medical Social Worker to ensure that review of the rights and responsibilities of residents in assisted living has been completed annually. Twelve resident files were identified as missing annual review of rights and responsibilities. Eleven of those files are now updated and written acknowledgement was placed in each resident?s record. The remaining resident file will be updated and documented by 10/7/2022. c. The Medical Social Worker will complete a review of resident?s annual rights and responsibilities on the resident?s move in date anniversary, yearly. This calendar will be kept up to date by the Medical Social Worker. d. The Administrator of Assisted Living or designee will educate the Medical Social Worker on the requirement to review all resident?s annual rights and responsibilities every year on their move in anniversary, with each resident or their legal representative or responsible individual. The administrative nurse or designee will audit resident files for an annual rights and responsibilities once a week for two weeks, once a month for two months and once a quarter for two quarters. Audit findings will be reported to the Administrator of Assisted Living and the Administrator of Health Services and any areas of concern will be addressed.
Standard #:	22VAC40-73-980-A
Description:	Based on a review of the facility?s first aid kit the facility failed to ensure that the first aid kit contained all required items. Evidence: -The first aid kit did not contain the First Aid instructional manual. Staff # 6 stated that she was not sure why the instructional manual was not in the first aid kit and would make sure it was replaced.
Plan of Correction:	a. The first aid kit cited now contains the First Aid instructional manual. b. The Administrator of Assisted Living audited all 5 first aid kits used in the assisted living area and ensured that the kits were complete. Administrator of Assisted Living placed content list on the top of each first aid kit. c. The Administrator of Assisted Living or designee will educate all assisted living team members regarding the first aid kits located on each floor and the required contents. The Administrative Nurse will be responsible for checking the kits on a monthly basis and documenting findings in a log maintained with each first aid kit. d. The Administrative Nurse or designee will audit the first aid kits once a week for two weeks, once a month for two months and once a quarter for two quarters. Audit findings will be reported to the Administrator of Assisted Living and the Administrator of Health Services and any areas of concern will be addressed.
Standard #:	22VAC40-90-40-C
Description:	Based on a review of staff records the facility failed to ensure that any person required to obtain a criminal history record report shall be ineligible for employment if the report contains convictions of the barrier crimes. Evidence: The record for Staff # 5 (date of hire: 9-14-2021) contained a criminal history report dated 8-30-2021 with a barrier crime of Misdemeanor Assault per VA Code Section 18.2-57. The administrator stated that the staff member would be terminated.
Plan of Correction:	a. Staff member #5 was terminated August 24, 2022. b. All personnel files for assisted living team members have been reviewed to ensure that no team member has a barrier crime. All background checks were in place and no barrier crimes were identified. c. The Administrator of Assisted Living will educate the Human Resources Director on barrier crimes and that team members cannot begin resident care until their background has come back and it does not include any barriers crimes. Administrator of Assisted Living will educate using the DSS update dated August 5, 2022, which described ?barrier crimes.? The Human Resources Director will provide the Administrator of Assisted Living with background reports of potential new assisted living employees which show any criminal background information for the Administrator?s approval/denial before employment begins. The Administrator of Assisted Living will initial and date upon review. The Administrator of Assisted Living or designee will complete a 100% audit of Annual Sworn Statement or Affirmation shall be made of each assisted living employee?s file by October 31, 2022 d. The Administrator of Assisted Living or designee will conduct an audit of all new hire personnel files once a week for two weeks, once a month for two months and once a quarter for two quarters. Audit results will be reviewed by the Administrator of Health Services and any areas of concern will be addressed.