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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments:
Type of inspection: Monitoring An unannounced on-site monitoring inspection was conducted on 7-25-24. AR 07:42 a.m./dep 15:50 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: 20 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Based on interview, the facility failed to ensure it reported to the licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health or safety, or welfare of any resident.
Evidence: 1. On 7-25-24, resident #2?s July 2024 medication administration record (MAR) noted, 7-17-24, ?cleanse Stage 2 gluteal cleft wound with ward, soapy water, dry, apply Curad twice a week?. A hospice plan of care update report printed 07/16/2024 08:56 AM noted. ?Order date 07/14/2024, approved date 07/16/2024, Order Type Hospice physician order. Cleanse STG II Gluteal Cleft wound with warm, soapy water. Dry. Apply non-adherent dressing 2xweekly and PRN if soiled or dislodged?. This document is electronically signed on 7-14-2024 and 7-16-2024 by two different registered nurse (RN) and wet signature by the licensed practitioner on 7-22-24. Staff #2 was inquired about the resident?s stage 2, to which staff stated the resident did not have a stage 2. Staff #2 contacted the hospice agency who provided the facility a copy of the Wound Record Report which noted Gluteal cleft-coccyx, Stage II, onset date 7-14-24.
Plan of Correction:
Administrator/Designee will report any major incident that has negatively affected or that threatens the life, health, or safety, or welfare of any resident within 24 hours to the licensing office.
Standard #:
22VAC40-73-210-B
Description:
Based on record reviewed and staff interviewed, the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff who are licensed health care professionals or certified nurse aides shall attend at least 12 hours of annual training.
Evidence: 1. On 7-25-24, staff #3?s record did not have documentation of staff?s annual training hours. 2. Staff #1 and #2 acknowledged, the staff?s record did not have the required annual training hours.
Plan of Correction:
Administrator/Designee will ensure that all assisted living facility employees will attend their required staff training hours by October 5, 2024. Administrator will audit staff training records monthly for the next three months to ensure compliance.
Standard #:
22VAC40-73-210-F
Description:
Based on record reviewed and staff interviewed, the facility failed to ensure at least two of the required hours of training shall focus on infection control and prevention. When adults with mental impairments reside in the facility, at least four of the required hours shall focus on topics related to residents? mental impairments.
Evidence: 1. On 7-25-24, staff #3?s record included a certificate of completion with two (2) of the required four (4) hours of mental impairment training when residents with impairments resident in the facility. 2. Staff #1 and #2 acknowledged the staff?s record did not include all the required mental impairment training.
Plan of Correction:
Administrator/Designee will ensure that all assisted living facility employees will attend their required infection control and mental impairment training hours by August 30, 2024. Administrator will audit staff training records monthly for the next three months to ensure compliance.
Standard #:
22VAC40-73-310-H
Description:
Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions or care needs for a resident.
Evidence: 1. On 7-25-24, during the medication pass observation with staff #3, resident #3 was administered Risperidone, prescribed 5-31-24. The resident?s July 2024 medication administration record (MAR) noted the resident was also prescribed Haloperidol 5-31-24. The record did not include a psychotropic treatment plan as required for these medications. 2. Staff #3 acknowledged; the resident?s record did not have a treatment plan for the prescribed psychotropic medications.
Plan of Correction:
Administrator/Resident Care Coordinator will ensure that all new admissions into the facility and any current residents have a completed psychotropic treatment plan for psychotropic medications, if applicable. Resident Care Coordinator will audit resident records weekly over the next three months to ensure compliance. Date to be completed: August 30, 2024.
Standard #:
22VAC40-73-450-D
Description:
Based on record reviewed and staff interviewed, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included in the individualized service plan (ISP).
Evidence: 1. On 7-25-24, resident #1?s record included documentation of activities of daily living (adl) care and volunteer/companion services, social worker, and chaplain services. These services were not documented on the residents? ISP dated 6-14-24. Staff #2 stated caregiver came and provided residents with bathing, transferring and dressing on Tuesday and Thursday. Hospice services start of care noted date 7-10-23. 2. Resident #2?s record included documentation of ADL care, volunteer/companion, social worker and chaplain services. These services were not documented on the resident?s ISP dated 6-17-24. 3. Staff #2 acknowledged the residents? ISP did not include all services provided, including hospice services
Plan of Correction:
Resident Care Coordinator will audit all current resident ISPs to ensure that hospice services are listed on their individualized care plan, if applicable. Audits will be completed by August 30, 2024. Resident Care Coordinator will audit all ISP's monthly to ensure compliance.
Standard #:
22VAC40-73-550-G
Description:
Based on record reviewed and staff interviewed, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities was reviewed annually with each resident or his legal representative or responsible individual as stipulated in the regulations and each staff person. Evidence of this review shall be written acknowledgement of having been so informed and include the date of the review and shall be filed in the resident?s or staff person?s record.
Evidence: 1. On 7-25-24, resident # 4?s record noted the last signed and dated resident?s rights and responsibilities was signed 11-6-21 and 10-6-22. 2. Staff #1 and #2 acknowledged the resident?s rights and responsibilities was not reviewed annually.
Plan of Correction:
Administrator will audit all current resident records to ensure that an updated rights and responsibilities of resident in assisted living facilities have been reviewed within the past year. Audits will be completed by August 30, 2024. Administrator will randomly audit all resident records quarterly for the next six months to ensure compliance.
Standard #:
22VAC40-73-680-I
Description:
Based on document reviewed and staff interviewed, the facility failed to ensure the facility?s medication administration record (MAR) include the diagnosis, condition, or specific indications for administering the drug or supplement.
Evidence: 1. On 7-25-24 during the medication pass observation with staff #3, resident #1?s July 2024 medication administration record (MAR) did not include the diagnosis, condition or specific indications for the following prescribed medications: (a) Amlodipine and (b) Multivitamin. 2. Staff #3 acknowledged the resident?s MAR did not include the required information.
Plan of Correction:
Resident Care Coordinator has completed an audit of all current resident medication administration records (MAR) to ensure diagnosis, condition, or specific indications for administering drugs or supplements are included in all medications. Resident Care Coordinator will audit all resident MAR's weekly to ensure compliance. Corrected as of August 7, 2024.
Standard #:
22VAC40-73-860-G
Description:
Based on observation and staff interviewed, the facility failed to ensure the hot water at taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F.
Evidence: 1. On 7-25-24, during a tour of the facility with staff #1, the water temperature in resident?s bathroom #C-7 was observed to be 123.7 degrees F. 2. The temperature in the resident?s bathroom in #C-15 was observed to be 130.3 degrees F. 3. Staff #1 acknowledged the water temperatures were not maintained with the required range at taps available to residents.
Plan of Correction:
Maintenance Director has corrected current water temperatures to be compliant with state regulations. Maintenance Director will randomly audit all room water temperatures monthly to ensure compliance. Corrected as of August 7, 2024.
Standard #:
22VAC40-73-990-C
Description:
Based on observation and staff interviewed, the facility failed to ensure first aid kits were checked at least monthly to ensure that all items are preset and items with expiration dates are not past their expiration date.
Evidence: 1. On 7-25-24, the first aid kit from the facility?s motor vehicle used to transport residents was check with staff #4. The alcohol prep pad had an expiration date of 3-25-24 and the antiseptic ointment had an expiration date of 03-25-24. The cold pack was also missing from the kit. 2. Staff #2 and #4 acknowledged the first aid kit for the motor vehicle did not have all required items and/or items were expired.
Plan of Correction:
Administrator has updated and checked all current first aid kits to ensure compliance with state regulations. Administrator will audit all first aid kits monthly to ensure compliance with state regulations. Corrected as of August 7, 2024.
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.
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