Virginia DSS · Assisted Living Facility

The Village at Orchard Ridge

📍 400 Clocktower Ridge Drive, Winchester, VA, 22603

ID 39659Two Year licenseActive
16
Inspections
On record
8
With violations
Visits that cited something
8
Clean visits
Nothing cited
16
Violations cited
Individual findings
13
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

The Village at Orchard Ridge was inspected 16 times between February 2, 2021 and November 6, 2024 by the Virginia Department of Social Services. 8 of those visits ended with violations cited and 8 with none. Across that history VDSS cited 16 violations under 13 distinct standards. 1 inspection was prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 14 of these 16 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
11/26/2026
Administrator
Melissa Sellers
Licensing inspector
Margaret Woods-Kane
Inspector phone
(804) 724-9618
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

16

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

November 6, 2024Inspection1 violation
Inspection dates
11/06/2024, 11/07/2024
Areas reviewed
¿ 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES¿ 22VAC40-73 PERSONNEL¿ 22VAC40-73 STAFFING AND SUPERVISION¿ 22VAC40-73 RESIDENT CARE AND RELATED SERVICES¿ 22VAC40-73 BUILDINGS AND GROUND¿ 22VAC40-73 EMERGENCY PREPAREDNESS¿ 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS¿ 63.2 GENERAL PROVISIONS¿ 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
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/06/2024 9:00 a.m. -5:00 p.m. and 11/07/2024 9:00 a.m. to 5:00 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: 37 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed:4 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 4 Observations by licensing inspector: The Licensing Inspector observed staff engaged with the residents during activities, meal and medication administrations. The following were reviewed at the time of inspection: Menus, activity calendars, fire drills, emergency drills, resident council minutes, dietician report, healthcare and medication oversight, Fire Marshall and Virginia Department of Health inspections. Additional Comments/Discussion: Reviewed 690 F 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 Jill James, Licensing Inspector at 540-418-2631or by email at jill.james@dss.virginia.gov
Violations
22VAC40-73-250-D
Based on record review and staff interview, the facility failed to ensure that staff annually submitted the results of a risk assessment, documenting that the individual was free of tuberculosis (TB) in a communicable form as
Evidence
  1. d by the completion of a current screening form published by the Virginia Department of Health (VDH) or a form consistent with it. Evidence: 1.Employee files reviewed for staff 2 (date of hire 07/15/2024); staff 4 (date of hire 04/10/2023) and staff 5 (date of hire 09/12/2022) included a facility developed form for tuberculosis screening which evaluated for symptoms but not the risk areas listed on the VDH updated form for travel, medical conditions, immunosuppression.
  2. On 11/07/2024 Staff 1 acknowledged the facility only uses a company created form.
Plan of correction
250-D The Healthcare Administrator or designee will assure the Virginia tuberculosis screening form is used rather than the organization form to assure substantial compliance with the Virginia Assisted Living Guidelines. All team members received communication on November 7, 2024 of this update.
October 11, 2023Inspection1 violation
Inspection dates
10/11/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 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: LI entered the facility at 8:30 am on 10/11/2023 and exited at 2:30 pm. 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: 33 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: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed medication administration. LI observed residents eating breakfast and lunch and engaging in activities. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov
Violations
22VAC40-73-680-D
Based upon a review of records, the facility failed to ensure that medications were administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The hydralazine HCl order for Resident #3 (R3) states “give 1 tablet by mouth two times a day. Hold for systolic blood pressure less than or equal to 130.”
  2. The Medication Administration Record (MAR) for August 2023 documented that R3 was administered hydralazine on 8/12/2023 and 8/22/2023 when the documented systolic blood pressure was less than or equal to 130.
  3. The MAR for September 2023 documented that on 9/5/2023 and 9/23/2023 R3 was administered hydralazine when the documented systolic blood pressure was less than or equal to 130.
  4. The MAR for October 2023 documented that on 10/6/2023 R# was administered hydralazine when the documented systolic blood pressure was less than or equal to 130.
Plan of correction
A full audit was performed by the RN Care Coach on all Assisted Living residents currently on blood pressure medications to ensure the electronic medical record triggers for blood pressure to be checked prior to blood pressure medication being administered to a resident to ensure it is given within the correct parameters. Education will be provided to nurses, and CMAs by DON, RN Care Coach or designee to follow blood pressure parameters as indicated in physician orders to prevent reoccurrence by 11/15/2023. Routine and random medication pass observations to be completed by DON, RN Care Coach, or designee.
May 25, 2023Complaint survey0 violations
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
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 05/25/2023 regarding allegations in the area(s) of: Resident Related Services 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. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: assisted living kitchenette area, menu, staff and resident interactions Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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. 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 Rhonda Whitmer, Licensing Inspector at (540) 292-5932 or by email at rhonda.whitmer@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 25, 2023Inspection0 violations
Inspection dates
05/25/2023
Areas reviewed
63.2 PROTECTION OF ADULTS AND REPORTING
Comments
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 05/18/2023 regarding allegations in the area(s) of: Protection of Adults and Reporting. Number of residents present at the facility at the beginning of the inspection: 15 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: resident and staff interactions Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-reported incident of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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. 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 Rhonda Whitmer, Licensing Inspector at (540) 292-5932 or by email at rhonda.whitmer@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 15, 2023Inspection1 violation
Inspection dates
03/15/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Recommended having staggered times for shift report for nurses and certified nursing assistants.
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/15/2023 from approximately 11:45 am to 4:15 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 3/14/2023 regarding allegations in the area of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 14 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 (outside agency private duty personnel) Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 6 Observations by licensing inspector: Mealtime and resident and staff interactions Additional Comments/Discussion: Discussed additional interventions and changes to implement. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov
Violations
22VAC40-73-220-A
Based upon documentation and interviews, the facility failed to ensure companion services were included on one of one individualized service plan (ISP) and that documentation was maintained on the care provided by the two private duty personnel (PDP).
Evidence
  1. The ISP (updated 12/28/2022) for resident 1 did not include the private duty services (PDS) provided.
  2. On 3/15/2023, the licensing inspector (LI) interviewed staff 2 who stated the PDS were not listed on resident 1’s ISP.
  3. The notebook for documenting PDS for resident 1 did not include any documentation for 1/28/2023 - 1/29/2023, 2/2/2023 – 2/5/2023, 2/7/2023 – 2/8/2023, 2/10/2023, 2/15/2023 – 2/19/2023, 2/21/2023 – 2/24/2023, 2/26/2023 – 2/28/2023, 3/2/2023 – 3/13/2023.
  4. On 3/15/2023, the LI interviewed staff 1 and 2 and both stated the PDS provided were not documented daily, as the services were provided.
Plan of correction
The ISP for resident 1 was immediately corrected by the Director of Nursing to include care companion services. As soon as care companion services are implemented, the Registered Nurse (RN) Care Coach will assure it is included in the resident’s ISP. The RN Care Coach or designees will adjust the ISP as any changes occur, including changes with the care companion service hours. The care companion was notified and made aware that documentation needs to be completed at the end of the scheduled shift. The nurse or certified nursing assistant (CNA) will assure the care companion has completed documentation prior to leaving at the end of the scheduled shift. The RN Care Coach will do a weekly visual audit to assure care companion documentation has been completed throughout the week.
January 20, 2023Inspection0 violations
Inspection dates
01/20/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/20/2023 from approximately 10:50 am to 3:40 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 1/17/2023 regarding allegations in the area of: resident care Number of residents present at the facility at the beginning of the inspection: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 5 Observations by licensing inspector: Staff and resident interactions, meal time, resident rooms and activities. Additional Comments/Discussion: Documented interventions and training were reviewed. Thank you for your assistance and cooperation during this inspection. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 19, 2023Inspection1 violation
Inspection dates
01/19/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Recommended an in-service be conducted with all nurses and registered medication aides on administering nasal sprays, eye drops, etc., as well as proper hand hygiene and proper use of the medication cart. Also recommended more frequent medication administration audits be conducted and some be conducted when staff are unaware of being observed.
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/19/2023 from approximately 8:30 am to 1:30 pm. 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: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 (selected sections only) Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Medication administration observations, review of medication administration records and physicians’ orders. Additional Comments/Discussion: Licensing inspector (LI) reviewed the December and January medication administration records and signed physicians’ orders for three residents. LI also observed one nurse and one registered medication aide administer medications. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov
Violations
22VAC40-73-100-C-1
Based upon documentation, the facility failed to implement the facility’s infection control policy regarding hand hygiene.
Evidence
  1. On 1/19/2023, the licensing inspector (LI) observed staff 1 at the medication cart on the assisted living unit. A plastic cup with a lid was setting on top of the cart. LI asked staff 1 if that was her personal cup and she stated, “Yes.”
  2. On 1/19/2023, the LI observed staff 1 prepare to pop medications for resident 3. As she started to pop the medication, the LI asked her if she had washed or sanitized her hands and she stated “No.” The LI asked how often she washed her hands or used hand sanitizer when administering medications and she stated, “Maybe after every two or three residents.”
  3. On page 2, #7, of the facility’s infection control policy it states, “Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty. b. before and after direct contact with residents; c. Hand washing before preparing and administering each residents medication.”
Plan of correction
Staff 1 was immediately educated not to have a personal beverage on the medication cart and to practice hand hygiene between each resident for medication administration passes. Education will be provided to nurses and registered medication aides (RMAs) by director of nursing (DON), registered nurse (RN) Care Coach or designee to follow the infection control practice of not having personal beverages on the medication cart and practicing hand sanitation between medication administration to each resident. Routine, and random medication pass observations to be completed by DON, RN Care Coach or designee.
November 9, 2022Inspection4 violations
Inspection dates
11/09/2022, 11/10/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
1. Ensure the model form for fire drills that does not include the corrective action taken column is destroyed and only use the one the facility has updated. 2. On the lift training roster, specify the type of lifts staff were trained on. 3. Ensure residents sign the orientation form even when the legal representative signs it. 4. Rather than leaving not applicable sections of forms blank, recommended putting ”N/A” so it doesn’t give the appearance of being overlooked/missed (social data forms, etc.). 5. On the volunteer orientation form, specify what reporting requirements was reviewed as well as put the title of the volunteer supervisor next to his/her name. 6. Met with the dietician and answered questions and clarified information in the standards. Recommended creating a form that includes all of the information in the dietary review standards and then send it to the licensing inspector for review.
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: 11/9/2022 from approximately 8:30 am to 6:20 pm and 11/10/2022 from approximately 7:30 am to 6:30 pm 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: 27 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 + selected sections of 2 additional records Number of staff records reviewed: 4+ 1 Volunteer + selected sections of 4 additional records Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 6 + 2 collateral Observations by licensing inspector: Activities, meals, special diets, medication administration, medication carts and postings Additional Comments/Discussion: Met with multiple staff and residents regarding facility procedures, training, resident care, staffing, etc. 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov
Violations
22VAC40-73-680-D
Based upon documentation and interviews, the facility failed to ensure one medication for one of three residents reviewed was administered according to the physician’s order.
Evidence
  1. Resident 1 had a signed physician’s order dated 8/23/2022 for “One 37.5mg tablet Metoprolol Tartrate two times a day for bradycardia hold for SBP<95 DBP<65 or HR<55.”
  2. On 10/6/2022, resident 1’s blood pressure (BP) was 96/62; on 10/7/2022 BP was 103/62; on 10/10/2022 BP was 118/64; on 10/15/2022 BP was 98/64; on 10/24/2022 BP was 100/64; on 10/25/2022 BP was 104/64. According to the staff initials on the medication administration record (MAR), the medication was administered on all of the above dates.
  3. On 11/9/2022, the licensing inspector (LI) interviewed the care coach who also reviewed the MAR and stated the medication was given in error on the above dates.
Plan of correction
-A full audit was performed by the registered nurse (RN) care coach on all assisted living residents currently on blood pressure medications to assure the electronic medical record triggers for a blood pressure to be checked prior to blood pressure medication being administered to a resident to assure it is given withing the correct parameters. -Education will be provided to nurses, and registered medication aides (RMAs) by director of nursing (DON), RN care coach or designee to follow blood pressure parameters as indicated in physician orders to prevent reoccurrence. -Routine, and random medication pass observations will be completed on at least one team member weekly by DON, RN care coach or designee.
22VAC40-73-260-C
Based upon documentation and an interview, the facility failed to ensure the posted list of staff with first aid (FA) and cardiopulmonary resuscitation (CPR) remained up to date.
Evidence
  1. On 11/9/2022, the LI observed a posted list of staff with FA and CPR on the secured unit and the assisted living unit and it indicated the list was last “updated on 07/23/2022.”
  2. According to the staff list submitted to the LI on 11/9/2022, there were 13 direct care staff/nurses hired since 7/23/2022, none of which were listed on the posted FA/CPR list.
  3. On 11/9/2022, the LI interviewed the care coach who stated the list was not current and did not include the staff hired since 7/23/2022 who had current certification in FA/CPR. .
Plan of correction
-Upon notification by the licensing inspector, the first aid and CPR certification list was immediately updated in both care bases by the administrative support clerk. -RN care coach, administrative support clerk, or designee will assure the first aid and CPR certification list is updated upon hire and as team members receive training. -RN care coach, healthcare administrator, or designee will perform routine walking rounds to assure compliance.
22VAC40-73-610-B
Based upon observations and an interview, the facility failed to ensure the current weekly meal and snack menu was posted.
Evidence
  1. On 11/9/2022, the LI observed on the assisted living unit the posted menu which was dated for the week of 10/9 through 10/15.
  2. On 11/9/2022, the LI interviewed staff 1 who was the staff in charge of the unit, and she stated she had notified the kitchen staff several times that a current menu was needed; however, it was not received.
Plan of correction
-Upon notification by the licensing inspector, a new dining menu was immediately posted by the dining director. -A designated team member from dining will post the updated menu weekly each Saturday evening to reflect the menu for the upcoming week. -RN care coach, dining director, and healthcare administrator will perform routine audits to assure compliance.
22VAC40-73-680-G
Based upon observations and an interview, the facility failed to ensure two over-the-counter (OTC) medications were labeled with a pharmacy label or the resident’s name.
Evidence
  1. On 11/9/2022, the LI conducted a medication cart audit along with staff 1 on the assisted living unit. There was a bottle of Acetaminophen and a bottle of Multi-Carotene and neither bottle of medication had a pharmacy label or the resident’s name on the bottles.
  2. On 11/9/2022, the LI interviewed staff 1 who checked both medication bottles and stated the medications should have been labeled with the resident’s name.
Plan of correction
-Upon notification by the licensing inspector, a label was placed on the two over the counter medications. -RN care coach will educate team members to assure proper labeling directly upon receipt for over-the-counter medications to prevent reoccurrence. -RN care coach or designee will perform audits upon admission and monthly to assure all medications are labeled appropriately.
October 25, 2022Inspection0 violations
Inspection dates
10/25/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 PROTECTION OF ADULTS AND REPORTING22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/25/2022 from approximately 1:10 pm to 3:45 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 10/22/2022 regarding allegations in the area of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 25 The licensing inspector completed a tour of the secured unit physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Staff and resident interactions Additional Comments/Discussion: None. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 8, 2022Inspection0 violations
Inspection dates
08/08/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/8/2022 from approximately 8:25 am to 12:00 pm. 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: 18 Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Conducted medication administration observations for two residents. Additional Comments/Discussion: This inspection was conducted as a focused inspection due to previous violations. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 25, 2022Inspection0 violations
Inspection dates
07/25/2022
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/25/2022 from approximately 9:50 am to 12:25 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. An announced inspection was conducted on 7/25/2022 to measure the window space and square footage of 17 bedrooms. Bathrooms were also randomly checked for all required items, including handrails. The 17 rooms were in the independent living building on the third floor. The facility has requested two hallways, including the 17 rooms and common areas in this specific area be licensed as assisted living. One of the rooms was requested for single occupancy and sixteen rooms for double occupancy. The administrator has requested the licensed capacity be increased from 18 to 51; however, the total new capacity will be determined once the square footage calculations have been completed. The building official's approval, fire inspection and certificate of occupancy must be received in the licensing office prior to the rooms being approved and the new license being issued. Thank you for your assistance and cooperation during this inspection. Please do not hesitate to contact this inspector if you have any further questions or concerns. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Janice Knight, Licensing Inspector at (540) 430-9258 or by email at Janice.knight@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 15, 2022Inspection3 violations
Inspection dates
06/15/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Discussed the importance of conducting monthly audits of the electronic medication administration records and having specific protocols to ensure all medication orders are entered accurately within 24 hours using the correct processes.
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/15/2022 from approximately 10:35 am to 5:10 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 4/14/2022 regarding allegations in the areas of medication administration and documentation. Number of residents present at the facility at the beginning of the inspection: 14 Number of resident records reviewed: 3 (selected sections) Number of staff records reviewed: 3 (selected sections) Number of interviews conducted with staff: 6 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at Janice.knight@dss.virginia.gov
Violations
22VAC40-73-680-D
Based upon documentation, the facility failed to ensure one medication each for two of three residents’ were administered as ordered.
Evidence
  1. Resident 1 had a physician’s order signed 1/31/2022 to “Decrease eliquis to 2.5 mg BID day for GIB.”
  2. The eMARs for February, March and April (through 4/12/2022) did not include this new order and the medication was not administered.
  3. On 6/15/2022, the LI interviewed staff 1 who stated this medication was not administered as it did not show up on the eMAR because the nurse did not follow the proper order entry process.
  4. Resident 3 had an order signed 6/9/2022 for “Norvasc 10 mg by mouth in the morning for Hypertension Hold if Systolic is less than 130.”
  5. On 6/6/2022 blood pressure was documented as 126/84; on 6/7/2022 as 128/84 and on 6/14/2022 as 128/74. The eMAR was initialed by staff 3 as medication administered on these three days.
Plan of correction
Resident 1 was seen and examined by nurse practitioner on 4/19/2022 and Eliquis was resumed. A cardiologist appointment was also scheduled, and resident was seen by her cardiologist on 5/16/2022. Resident 1’s record was reviewed, and no similar error was identified. Other residents’ records were reviewed, no similar error was identified. Monthly orders, eMARs, and eTARs reviews will be completed by DON, AL Manager, or designee. Day shift nurses will check orders entered by night shift nurses. Education will be provided to nurses, CMAs by DON, AL manager or designee, on medication order entry. Education will be provided to nurses, and CMAs by DON, AL manager or designee to follow blood pressure perimeters as indicated in physician orders. Routine, and random med pass observations to be completed by DON, AL manager or designee
22VAC40-73-640-A
Based upon documentation and interviews, the facility failed to ensure implementation of the medication management plan by reviewing a changed medication order within 24 hours of receipt to ensure accurate transcription and to conduct monthly reviews of the electronic medication administration records (eMARs) for one of three resident records reviewed.
Evidence
  1. Resident 1 had a physician’s order signed 1/31/2022 to, “Decrease Eliquis to 2.5 mg BID for GIB.”
  2. The February, March and April (through 4/12/2022) eMARs did not include this new order.
  3. On 6/15/2022, the licensing inspector (LI) interviewed staff 1 who stated staff 2 entered the information; however, she clicked the wrong button when entering the order and it was not added to the eMAR. Staff 1 also stated staff 2 was the nurse on duty who was supposed to check the order within 24 hours to ensure it was entered correctly and since she was the one who entered the information she did not conduct the second check.
  4. On 6/21/2022, the LI conducted a telephone interview with staff 2, night shift charge nurse, and she stated, “I didn’t put the order under pharmacy but I put it under other. I was aware of the correct way to enter it but I made a mistake. I guess I wasn’t thinking and I didn’t recheck it within 24 hours since I was the one who entered the order.”
  5. The section of the medication management plan titled “Physician Order Accuracy Assurance” states, “All physician orders will be double checked by the night shift charge nurse/med tech for accuracy and proper documentation within 24 hours of receipt of a new order or change in order.”
  6. The section of the medication management plan titled “Medication Management Policy, Policy Interpretation and Implementation” states, “Regular audits by DON or designee to monitor medication administration and the effective use of the electronic medication administration record (eMAR) documentation: this process includes checking medication orders to ensure accuracy and request discontinuation of unnecessary medication to physician. Medication orders will be reviewed in electronic medical record monthly by DON or designee, then printed for physician to review and signed.”
Plan of correction
Resident 1 was seen and examined by nurse practitioner on 4/19/2022 and Eliquis was resumed. A cardiologist appointment was also scheduled and resident was seen by her cardiologist on 5/16/2022. Resident 1’s record was reviewed, and no similar error was identified. Other residents’ records were reviewed, no similar error was identified. Monthly orders, eMARs, and electronic treatment administration records (eTARs) reviews will be completed by director of nursing (DON), assisted living (AL) manager, or designee. Day shift nurses will check orders entered by night shift nurses. Education on medication order entry will be provided to nurses, and certified medication aides (CMAs) by DON, AL manager or designee.
22VAC40-73-680-I
Based upon documentation and an interview, the facility failed to ensure all required information was documented in the eMARs for three of three resident records reviewed.
Evidence
  1. The eMAR for resident 1 was blank for weight on 5/4/2022 and 5/27/2022.
  2. The eMAR for resident 2 was blank for Atorvastatin Calcium at 6:00 pm on 6/7/2022 and for cleansing the fourth toe on right foot on the 7:00 am to 7:00 pm shift on 6/7/2022 and 6/11/2022.
  3. The eMAR for resident 3 was blank on 6/7/2022 at 5:00 pm for Preservision AREDS and Refresh Tears.
  4. On 6/15/2022, the LI interviewed staff 3 who stated she failed to go back and initial the eMARs once the treatments/medications were administered.
Plan of correction
Resident records were reviewed. Nurses/CMAs involved will receive coaching and education to address blank eMARs. and documented coaching/corrective action will be entered in their files. Each nurse/CMA will pull a medication/treatment administration report at the end of each shift to verify and confirm that all due treatments/medications have been administered. The report will be submitted to the DON, AL manager, or designee. DON, AL manager or designee will review shift medication/treatment administration report submitted by staff.
November 8, 2021Inspection0 violations
Inspection dates
11/08/2021, 11/09/2021, 11/10/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
1. Recommended when an order has one type of eye drop and the pharmacy fills the order with a different type, this change be signed by the physician to ensure approval. 2. What to do if symptoms persist needs to be on each as needed medication listed on the signed medication sheet rather than one statement for all as needed medications. Ensure this process remains the same on the medication administration records as well. 3. Discussed conducting cart audits weekly on Sundays during night shift rather than monthly.
Comments
A non-mandated monitoring inspection was initiated on 11/8/2021 and concluded on 11/10/2021. A self-reported incident was received by the department regarding an incident in the area of medication administration and as a result of that inspection, this 60-day follow up inspection was conducted. The administrative support clerk was contacted by telephone to conduct the inspection. The licensing inspector emailed the administrative support clerk a list of documentation required to complete the inspection. The licensing inspector conducted a remote review of documentation and conducted a virtual inspection on 11/10/2021. The Information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 24, 2021Inspection1 violation
Inspection dates
09/24/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Recommended physician's orders and medication administration records reflect half a tablet by using 1/2 tablet rather than 0.5 tablet .
Comments
A non-mandated self-report inspection was initiated on 9/24/2021 and concluded on 9/24/2021. A self-reported incident was received by the department regarding allegations in the area of resident care and related services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported self-report of non-compliance with standards or law, and violations were issued. All violations can be found on the violation notice.
Violations
22VAC40-73-680-D
Based upon documentation and an interview, the facility failed to ensure one medication for one resident was administered according to the physician's order.
Evidence
  1. Resident 1 had a physician's order signed 9/9/2021 for, "Ativan Tablet 0.5 MG Give 0.5 tablet by mouth two times a day related to anxiety disorder, unspecified AND give 1 tablet by mouth at bedtime related to anxiety disorder, unspecified."
  2. The September medication administration record (MAR) for resident 1 listed, "Ativan Tablet 0.5 MG (Lorazepam) Give 0.5 tablet by mouth two times a day related to anxiety disorder, unspecified" at 9:00 am and 2:00 pm.
  3. Progress note for 9/21/2021 at 8:18 am stated, "Ativan Tablet 0.5 MG Give 0.5 tablet by mouth two times a day related to anxiety disorder, unspecified. Medication held due to resident being more drowsy than normal. DON made aware. Staff will continue to monitor."
  4. Progress note dated 9/21/2021 at 3: 34 pm stated, Ativan Tablet 0.5 MG Give 0.5 tablet by mouth two times a day related to anxiety disorder, unspecified. Medication held per NP request."
  5. Progress note dated 9/21/2021 at 5:51 pm stated, "On 9/21/2021 resident was noted to be drowsy with stable vital signs. A review of medications received in the past 24 hours revealed that on 9/20/2021 resident received 0.5mg of Ativan at 9:37 am, and 1:30 pm instead of 0.25 mg at 9:00am and 2:00pm as ordered. Resident was assessed. She was drowsy but able to arouse when called. She is alert and responsive, oriented to self and place."
Plan of correction
Education /in-service on medication administration was provided to the nurse involved and is on-going for all certified medication aides (CMAs) and nurses. Ativan order was discontinued and reordered by nurse practitioner with a clarification order. New orders added to the resident's medication profile will be reviewed by the night nurse and clarification of orders, if needed, on a daily basis. All new orders will be reviewed weekly by the director of nursing (DON). All nurses and CMAs working on the neighborhood will be educated on medication administration rights. Quarterly medication administration observations will take place. Resident's new orders will be reviewed on a weekly basis by the DON. Any actionable trends or patterns will be reported monthly to the Quality Assurance Performance Improvement (QAPI) committee. The DON, administrator or designee will be responsible to ensure compliance.
September 7, 2021Inspection4 violations
Inspection dates
09/07/2021, 09/08/2021, 09/09/2021, 09/10/2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 General Provisions63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Technical assistance
1. Carefully review all orders upon receipt and ensure they are signed and contain all information as required within 14 days (oxygen orders must include the source of the oxygen, such as portable tank and/or concentrator). 2. Even though no residents were receiving therapy, ensure this information is included on the individualized service plans (ISPs) and is noted as discontinued when the services stop. Also, now that the pandemic is over, ensure all ISPs (initial, annual and updates) are physically signed by the resident/legal representative. 3. The drug reference book must be replaced prior to 2022. 4. All incidents that may affect the health, safety and welfare of a resident must be reported within 24 hours. This requirement includes stage 2 and above derma ulcers, 911 being called, falls, etc.). 5. The orientation form must be signed by the resident as well as the legal representative; however, not just the legal representative. 6. Staff 3 must complete 10 hours of dementia training prior to 12/16/2021. 7. Recommended creating a checklist for the dietitian to sign and add to the summary. 8. First aid training for staff 2 is due by 9/12/2021.
Comments
An initial monitoring inspection was initiated on 9/7/2021 and concluded on 9/10/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 18. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed two staff and two resident records, one contract staff, selected sections of five additional resident and two staff records, activities calendar, menu, staff schedules, fire drills, health care oversight, dietary reviews, medication administration records, physicians' orders and other information submitted by the facility to ensure documentation was complete. A virtual tour and inspection was conducted on 9/10/2021. An exit interview was conducted with the administrator on the date of the virtual inspection, where findings were reviewed and an opportunity was given for questions as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-700-1
Based on documentation and an interview, the facility failed to ensure four of the four oxygen orders included all required information.
Evidence
  1. The signed oxygen orders for residents 2 (signed 9/10/2021), 3 (signed 9/9/2021), 6 (signed 09/10/2021) and 7 (9/10/2021) did not include the source of the oxygen.
  2. On 9/10/2021, the LI interviewed the DON who checked the orders and stated they did not include the source of oxygen.
Plan of correction
The DON contacted the physicians and the orders were corrected immediately. All residents have been monitored and there are no adverse reactions as a result of this violation. An audit of all oxygen orders was conducted immediately by the DON. All oxygen orders were corrected to include oxygen source - oxygen concentrator or oxygen tank. An ongoing audit will be conducted every week for the next three months. The DON, staff educator, or designee will provide education to nurses and certified medication aides on proper oxygen orders to assure they include oxygen source. The DON, staff educator or designee will ensure compliance with this standard. Any actionable trends or patterns will be reported monthly to the QAPI Committee.
22VAC40-73-680-M
Based on documentation, observations and an interview, the facility failed to ensure one medication for one of two residents was available at the facility.
Evidence
  1. Resident 2 had a physician's order signed on 8/6/2021 for morphine sulfate, 0.25ml by mouth every four hours as needed (PRN) for pain.
  2. The August and September medication administration records (MARs) listed, "Morphine sulfate (Concentrate) Solution 20MG/ML Give 0.25ml by mouth every 4 hours as needed for pain. Use PRN for pain AEB moaning, grimacing."
  3. On 9/10/2021, the LI conducted a virtual audit of the medication cart along with the DON and the morphine sulfate could not be found.
  4. On 9/10/2021, the LI interviewed the DON who stated the medication may be in the stat box.
  5. On 9/10/2021, the DON checked the stat box and stated the morphine sulfate was not in the stat box.
Plan of correction
The DON assured the PRN medication was ordered immediately through the facility pharmacy provider. An audit of all ordered medications will be completed to assure all ordered medications are readily available. Medications will be ordered from the pharmacy upon receiving orders from physician for new medications. Medications will be ordered, or family will be notified, within five days prior to the last dose being administered to ensure no missed doses. The DON, LPN or designee will be responsible to ensure compliance. The DON, LPN, or designee will perform audits monthly. Any actionable trends or patterns will be reported monthly to the QAPI Committee.
22VAC40-73-450-C
Based upon documentation, the facility failed to ensure one of two individualized service plans (ISPs) reviewed was completed with all assessed needs within 30 days of admission.
Evidence
  1. Resident 2 was admitted 7/28/2021 and the most current ISP on file was dated as completed and signed on 8/26/2021.
  2. The uniform assessment instrument (UAI) dated as completed on 7/14/2021, indicated resident 2 needed mechanical help with toileting, eating, and mobility; however, these needs were not included on the most current ISP.
  3. The UAI indicated resident 2 needed assistance with stairs; however, the ISP indicated supervision.
  4. The UAI indicated disorientation to place and time; however, this need was not addressed on the ISP.
  5. Fall risk rating completed on 7/28/2021 and 9/3/2021 indicated moderate risk; however, this need was not addressed on the ISP.
  6. The ISP for resident 2 did not include inability to use the emergency call system and the frequency of rounds required.
Plan of correction
The UAIs and ISPs on the residents affected will be corrected by the DON, social worker, LPN, or designee. An audit of completed ISPs for all new admissions within the last six months will be completed. Initial ISPs will be completed with all basic needs and signed within seven days prior to admission. The comprehensive ISP will be updated, completed with all needs and signed for all new residents within 30 days. The DON, social worker, or designee will be responsible to ensure compliance. The social worker and LPN will meet monthly to assure the UAIs and ISPs are aligned and signed. Any actionable trends or patterns will be reported monthly to the QAPI Committee.
22VAC40-73-70-A
Based upon documentation and an interview, the facility failed to report one major incident for one of two residents.
Evidence
  1. The progress note on 9/3/2021 at 2:23 pm for resident 1 stated, "Open area/redness on coccyx."
  2. The nursing progress note on 9/3/2021 at 4:13 pm stated, "Current open area (stage 2) on resident's right buttock with epithelium tissue."
  3. The only report submitted to the licensing office for the stage 2 was received on 9/10/2021.
  4. On 9/10/2021, the licensing inspector (LI) interviewed the director of nursing (DON) who stated the stage 2 was not reported within 24 hours.
Plan of correction
A seven day incident investigation report was completed by the DON and submitted immediately to the LI. Recent incidents will be reviewed by the DON, administrator, or designee to evaluate if criteria are met for reportable incidents. All team members will be re-educated on an annual basis regarding mandated reporting major incidents to licensing. All team members will be sent the policy regarding mandated reporting major incidents to licensing. All new team members will receive training on reporting major incidents during new staff orientation. The DON, administrator staff educator, or designee will be responsible to ensure compliance. The change in condition assessments will be completed in Point Click Care (PCC) by the licensed practical nurse (LPN) to assist in documentation and requirements for notifications. Any actionable trends or patterns will be reported monthly to the Quality Assurance Performance Improvement (QAPI) Committee.
February 2, 2021Inspection0 violations
Inspection dates
Feb. 2, 2021
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 Protection of adults and reporting
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 monitoring inspection was initiated on 2/2/21 and concluded on 2/2/21. A self-reported incident was received by the department regarding allegations in the area of resident care. The administrator and nurse in charge were contacted by telephone to conduct the investigation. The licensing inspector requested information from both staff and the documentation required was submitted to complete the investigation. The evidence gathered during the investigation did not support the self-report of non-compliance with standard or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.