Inspection dates
Sept. 19, 2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND
Comments
Violations
22VAC40-73-250-C
Based on a review of three staff files, the facility failed to maintain documentation and
verification of medication aide provisional authorization from the Virginia Board of Nursing.
Evidence
- Documentation and verification of medication aide provisional authorization was not found during a review of the file for
staff # 2.
Plan of correction
Documentation was misplaced and staff member had yet to take the board exam She was removed as a Medication Aide
and placed on the schedule as a PCA.
22VAC40-73-260-A
Based on a review of direct care staff 1st Aid certifications, one staff does not have certification in 1st Aid.
Evidence
- The facility did not have documentation to support that staff # 7 had current 1st Aid certification.
Plan of correction
Direct care staff was scheduled to be in CPR/FA class on 9/13/22, however due to car issues was unable to attend. She is
scheduled for the next class on 10/25/2022. She never worked without having someone working with her that is CPR/FA
certified.
22VAC40-73-450-E
Based on a review of 5 resident files, the individualized service plan (ISP) for one resident
was not signed and dated by the resident or legal representative of the resident.
Evidence
- A review of the file for resident# 1 found that the current ISP dated 3/31/22 was not signed or
dated by the resident or the legal representative of the resident.
Plan of correction
ISP was emailed to family on individualized service plan 3/31/2022, however was never returned to GHS signed. ISP was
reviewed with the family and signed on 9/22/2022.
22VAC40-73-680-A
Based on a review of three staff files, medications are being administered to residents by a staff person who is not
currently registered with the Virginia Board of Nursing as a medication aide.
Evidence
- A review of the file for staff# 1 found an expired registration (expiration date is 5/31/22) with the Virginia Board
of Nursing.
Plan of correction
Due to the medication aide recently moving, she had lost her PIN and had requested a new one from the Virginia Board of
Nursing. PIN number was
received and license was renewed
22VAC40-73-680-D
Based on a review of physician orders, medication administration records (MARs)and drug count sheets, medications
were not administered in accordance with the physician's or other prescriber's instructions.
Evidence
- Medication was discovered by licensing staff in the facility's parking lot. As a result, licensing staff completed a
review of medication storage, availability and administration for three residents. Licensing staff found medications that
were not administered per physician orders:
- Resident # 10 has an order for Lorazepam Oral Concentrate: Give 0.25 ml sublingually 3 times a day - scheduled.
Lorazepam scheduled for administration at 9 am on 9/19/22 was not given. There was a note "med not given-given early".
The Drug Count sheet documents that the medication was given at 6 am on 9/19/22.
- Resident # 11 has an order for Lorazepam 1 mg: 1 tablet by mouth every 8 hours as needed for anxiety.
Lorazepam was not given every 8 hours. The Drug Count sheet documents Lorazepam being administered on 8/25/22 at
3: 15 pm and 9:00 pm, on 8/28/22 being administered at 10:00 am and at 5:00 pm and on 9/20/22 being administered at
11 :00 am and 3:00 pm.
Plan of correction
Not published by VDSS.
22VAC40-73-680-I
Based on a review of medication administration records (MARs) for September 2022 for four residents, MARs did not
have the date, time given and initials of staff administering
medications/treatments
medications/treatments.
Evidence
- The MAR for resident# 1 states knee brace -wear flexible knee brace every day and remove at bedtime. Placement of
knee brace is not documented on 9/2, 9/ 6, 9/7, 9/8, 9/9 or 9/11. The box on the MAR to document that the placement
occurred was blank.
- The MAR for resident # 2 states oxycodone 10 mg- 1 tab by mouth 3 times a day and gabapentin 100mg - 2 capsules
(200 mg) by mouth 3 times a day. The administration of oxycodone and gabapentin is not documented as being
administered on 9/6 and 9/8. The boxes on the MAR to document are blank.
Plan of correction
We have completed med pass observations on all medication aides as well as med cart audits. We have scheduled a Med
Tech Refresher to include review of the narcotic sheet by our pharmacy, Family Care.
22VAC40-73-870-D
Based on an inspection of the building and a random resident rooms along with interviews and observations of residents,
the facility is not free of infestations of insects and vermin and their breeding places.
Evidence
- A random inspection of resident rooms found evidence of bed bug infestation in two resident rooms:
- Two licensing inspectors observed excrement stains (dark spots) on the walls in the room of resident # 6.
- Two licensing staff observed blood-colored stains on the pillow and excrement stains (dark spots) on the walls and
bed sheets of the resident of the room of resident # 2.
Two licensing staff observed red, swollen areas on the arms, hands, fingers and upper chest of resident# 6.
Plan of correction
We are currently set up for monthly monitoring with Clean Heat Defense. If signs of bugs are seen in between services,
then Clean Heat comes out for special services. Clean Heat was called the day of inspection and was out the next
morning. They treated the two rooms where evidence was found as well as treated the entire third floor.