Current Inspector:
Angela Marie Swink
(276) 623-6575
Inspection Date:
Oct. 14, 2020
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.
Comments:
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 10/8/2020 and concluded on 10/14/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 5. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 2 resident records, 2 staff records, Fire and Health Inspections, employee schedule, fire drill logs, health care over sight and Dietician reports submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Based on a review of resident records and staff interviews, the facility failed to provide a written report of a resident incident to the regional licensing office within seven days from the date of the incident.
EVIDENCE:
1. The record for resident 1 has documentation of a physician order dated 5/28/2020 for wound care to an open area on the residents right buttocks. The facility did not provide a written report of this area within the required seven days.
Plan of Correction:
The Administrator will ensure that wounds and other incidents are reported as required.
Standard #:
22VAC40-73-440-D
Description:
Based on a review of resident records, the facility failed to ensure that uniform assessment instruments (UAIs) were completed as required.
EVIDENCE:
1. The private pay UAI dated 7/9/2020 in the record for resident 1 is incomplete as it does not have any documentation under the behavior pattern section of the form.
2. The private pay UAI dated 11/26/2019 and reassessed on 12/24/2019 is incomplete as it has documentation that the resident requires assistance with bathing and dressing but does not include what type of assistance(mechanical, supervision or physical) is required. Also the ISP dated 12/24/2019 for resident 2 has documentation that the resident requires assistance with orientation in the form of reminders as to the residents bedroom and other areas of the facility. The resident UAI is inconsistent as it has documentation that the resident is alert and oriented and requires no assistance.
Plan of Correction:
The Administrator will update resident UAI's to ensure accuracy and will review regularly.
Standard #:
22VAC40-73-450-C
Description:
Based on a review of resident records, teh facility failed to address all identified needs on individualized service plans (ISPs).
EVIDENCE:
1. The record for resident 1 has documentation of the resident receiving wound care services from Hospice. The comprehensive ISP dated 6/16/2020 for resident 1 has services provided by Hospice but does not address what services the facility staff are providing in-between Hospice visits to meet the residents wound care needs.
2. The record for resident 1 has documentation of the resident being a low to moderate fall risk on a Morse Fall Scale dated 11/4/2019. The comprehensive ISP dated 6/16/2020/ does not address this identified need.
3. The record for resident 2 has a physician order dated 1/9/2020 for Seroquel 25 mg, half tablet once daily for severe agitation. The September 2020 medication administration record (MAR) has staff initials for administering this medication on 9/25/2020 and 9/26/2020. The comprehensive ISP dated 12/24/2019 does not address the identified need for monitoring the resident for severe agitation or services to be provided to assist the resident with this need.
Plan of Correction:
The Administrator will revise resident ISP's to include all identified needs and will review regularly.
Standard #:
22VAC40-73-680-I
Description:
Based on a review of resident medication administration records (MARs), the facility failed to ensure accurate documentation on resident MARs.
EVIDENCE:
1. The September 2020 MAR for resident 1 has documentation of a physician order for Dakin's solution wound care daily to the residents right buttocks. Staff person 3 and 4's initials are present on the MAR for providing this wound care but resident 1's record has Hospice notes that indicate that a Hospice nurse is coming out daily to preform this treatment. In an interview with staff person 3 it was expressed that Hospice is preforming the treatment but staff initials are present on the MAR as they are the ones that hand over treatment supplies to the Hospice nurse.
Plan of Correction:
The Administrator will in serve staff on proper documentation on resident MAR's and will ensure that Hospice continues to document wound care treatments.
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
Find this content at:
http://www.dss.virginia.gov/facility/search/alf.cgi