22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 22VAC40-80 COMPLAINT INVESTIGATION
Comments:
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/22/2024 arrival 10:30am departure time 2:10pm;09/09/2024 arrival time 10:00am departure time 3:45pm;10/04/2024 arrival 10:30am departure 1:30pm
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by VDSS Division of Licensing on 08/09/2024, 09/05/2024, 10/4/2024 regarding allegations in the area(s) of:: Administration and Administrative Services Personnel, Staffing and Supervision, Resident Care and Related Services, Resident Accommodations and Related Provisions, Protection of Adults and Reporting and Complaint Investigation
Number of residents present at the facility at the beginning of the inspection: 11
Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: The Inspector observed/toured the rooms of two bed bound residents which included the monitoring of the facility?s call bell system. An observation of facility?s food supply and emergency food supply. Review of Medication Administration Record (MAR), medication cart and secured Schedule II medication. Review of resident fire and resident emergency drills and medication carts.
Additional Comments/Discussion:
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaints but identified during the course of the investigation can also be found on the violation notice. 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.Haskins@dss.virginia.gov.
Based on an interview, it was determined that the facility did not ensure that they shall report to regional licensing office/Licensing Inspector within 24 hours any major incident that has negatively affected or that threatens the life, health, safety or welfare of any resident.
Evidence: 1. An incident occurred on 8/6/2024 involving resident #1 2. The Licensing Inspector was not notified of incident by Administrator until 8/13/2024 by phone.
Plan of Correction:
Not available online. Contact Inspector for more information.
Standard #:
22VAC40-73-150-C
Complaint related:
No
Description:
Based on interviews and review of the facility?s documentation, it was determined that the administrator shall be responsible for the general administration and management of the facility and shall oversee the day-to-day operation of the facility.
Evidence:
1. The facility did not have a daily log available to ensure that daily care (hygiene, first aid, etc.) is provided to residents during the onsite inspection. 2. The most recent incident log provided to the Licensing inspectors was dated 7/3/24 ? 7/10/24, 3. Inoperable call bell system in rooms of bed bound two residents. 4. Observation of limited current food supply in the facility?s kitchen after resident #4 reported at times that there was no food for residents. 5. Review of staff records confirmed limited to no training and no supervision of non-qualified staff. 6. Inspector observed/interviewed two bed bound residents (resident #2 and appear and smelled soiled
Plan of Correction:
Not available online. Contact Inspector for more information.
Standard #:
22VAC40-73-310-B
Complaint related:
Yes
Description:
Based on review of resident records, it was determined that the facility did not ensure that before an individual is admitted to the facility that a determination be made that the facility can meet the needs of the individual.
Evidence: 1. Resident #1 was admitted 8/3/24 with no medical physical exam, no UAI, no fall risk assessment, and no ISP. 2. During the onsite inspection, staff #1 was confirmed that resident #1 was admitted without a completed Universal Assessment Instrument (UAI) or a physical examination from resident?s PCP.
Plan of Correction:
Not available online. Contact Inspector for more information.
Standard #:
22VAC40-73-310-H
Complaint related:
Yes
Description:
Based on review of resident records, it was determined that the facility did not ensure that assisted living facility shall not admit or retain individuals with psychotropic medications without appropriate diagnosis and treatment plans.
Evidence: 1. The record for resident #1 contained a prescription for a psychotropic medication without appropriate diagnosis or treatment plans. 2. Staff #1 confirmed that medication that was bought in by son was administered with no doctor?s order for the medication
Plan of Correction:
Not available online. Contact Inspector for more information.
Standard #:
22VAC40-73-320-A
Complaint related:
Yes
Description:
Based on a review of resident records, it was determined that the facility did not ensure that within 30 days preceding admission, a resident shall have a physical examination by an independent physician.
Evidence: 1. Resident #1 was admitted to the facility on 8/3/24 without a physical examination. 2. Staff #1 confirmed that resident #1 was admitted without a physical examination.
Plan of Correction:
Not available online. Contact Inspector for more information.
Standard #:
22VAC40-73-325-C
Complaint related:
Yes
Description:
Based on review of resident records, it was determined that the facility did not ensure that when a resident falls the facility must show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls.
Evidence: 1. Resident #1 fell on 8/3/24 at approximately 1:00pm. 2. The record for resident #1?s record did not contain a Fall Risk Assessment. 3. Staff #1 reviewed the record for resident #1 and was unable to provide a Fall Risk Assessment.
Plan of Correction:
Not available online. Contact Inspector for more information.
Standard #:
22VAC40-73-350-C
Complaint related:
No
Description:
Based on review of resident records, it was determined that the facility did not ensure that each resident or his legal representative is fully informed annually, that he should exercise whatever due diligence he deems necessary with respect to information on any sex offenders registered pursuant to Chapter 9 (? 9.1-900 et. seq.) of Title 9.1 of the Code of Virginia, including how to obtain such information.
Evidence: 1. Documentation in a resident #2?s file was noted that he is a sex offender and was not registered with Virginia State Police. 2. None the resident records reviewed contained written acknowledgment of having been so informed.
Plan of Correction:
Not available online. Contact Inspector for more information.
Standard #:
22VAC40-73-460-A
Complaint related:
Yes
Description:
Based on interviews a review of resident records, and a review of facility documentation, it was determined that the facility failed to ensure that they shall assume general responsibility for the health, safety, and well-being of the residents.
Evidence: 1. Resident #1 fell on 8/3/24 and did not receive treatment from a licensed medical professional until 8/6/24 when resident #1 was taken to the hospital by a family member. 2. Upon arrival at the hospital resident #1 was diagnosed with Acute Hematoma-Brain bleed, hip fracture also known as Femoral Neck (hip) fracture and required emergency surgery 3. Resident #1 died Friday, August 16, 2024.
Plan of Correction:
Not available online. Contact Inspector for more information.
Standard #:
22VAC40-73-470-F
Complaint related:
Yes
Description:
Based on interviews, a review of resident records, and a review of facility incident logs, it was determined that the facility failed ensure that when the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately.
Evidence: 1. On 8/3/24 at approximately 1:00pm resident #1 fell at the facility and was not rendered any aid by facility staff. 2. Staff #4 who was present during the time of the incident did not contact local EMS for assistance with resident #1. 3. Staff #1 stated that resident #1 was limping after the fall. 4. Resident #1 only received medical attention from a licensed health care professional once her son picked up from the facility son three days later on 8/6/24. 5. A review of the medical records for resident #1 revealed that resident #1 arrived at the hospital?s Emergency Room on August 6, 2024, and was diagnosed with Acute Hematoma-Brain bleed, hip fracture also known as Femoral Neck (hip) fracture. Resident #1 required emergency surgery upon arrival and died Friday, August 16, 2024.
Plan of Correction:
Not available online. Contact Inspector for more information.
Standard #:
22VAC40-73-640-A
Complaint related:
No
Description:
Based on a review of the Medication Administration Records (MAR), it was determined that the facility did not ensure that methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence:
1. The Medication Administration Record (MAR) for resident #2?s for Morphine had five entries that were documented by staff #2 as ?wasted.? 2. During an interview, staff #2 was asked what the term ?wasted? meant as documented on the Medication Administration Record (MAR) for resident #2?s for Morphine. Staff #2 responded that she thought it meant resident ?refused?. In addition, staff #2 responded in the interview that although her signature was on the Medication Administration Record, she did not administer the medication and that she signed off as a witness for Staff #3, even though she didn?t witness Staff #3 administer the medication.
Plan of Correction:
Not available online. Contact Inspector for more information.
Standard #:
22VAC40-73-660-A-5
Complaint related:
No
Description:
Based on observation and interview, it was determined that the facility did not ensure that a medicine cabinet, container, or compartment shall be used for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility. Medications shall be stored in a manner consistent with current standards of practice.
Evidence: 1. Licensing Inspectors observed a vial of Morphine prescribed to a resident #2 being stored the kitchen?s refrigerator. The medication was not secured and was accessible all staff and residents.
Plan of Correction:
Not available online. Contact Inspector for more information.
Standard #:
22VAC40-73-930-A
Complaint related:
No
Description:
Based on observation and interviews, it was determined that the facility did not ensure that the assisted living facilities shall have a signaling device that is easily accessible to the resident in his bedroom or in a connecting bathroom that alerts the direct care staff that the resident needs assistance.
Evidence: 1. The call bell system for resident #2 and resident #5 were not operation during the inspection. 2. Both resident # 2 and resident #5 are bed bound and unable to leave their room without the assistance of staff. 3. Staff #1 confirmed that the call bell system was not operation in the rooms of resident #2 and resident #5.
Plan of Correction:
Not available online. Contact Inspector for more information.
Standard #:
22VAC40-73-950-G
Complaint related:
No
Description:
Based on tour of buildings and grounds and observation, it was determined that the facility did not ensure that in the event of a disaster, fire, emergency, or any other condition that may jeopardize the health, safety and welfare of residents, the facility shall take appropriate action to protect the health, safety and welfare of residents and take appropriate actions to remedy the conditions as soon as possible.
Evidence: 1. The facility does not have an evacuation plan for resident #2 and resident #5 who are both bound and reside on the second floor of the facility in the case of an emergency. 2. Staff #1 confirmed that the that there was no plan for how to assist resident #2 and resident #5 to evacuate the facility in an emergency.
Plan of Correction:
Not available online. Contact Inspector for more information.
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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http://www.dss.virginia.gov/facility/search/alf.cgi