Oakland Manor LLC

Based on file reviews, the facility did not ensure that each direct care staff member shall maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: Current certification in first aid was not documented in the files for staff # 1 and # 2.

Based on file review, the facility did not ensure that each staff person or household member required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: The files for staff # 1 and # 2 did not have documentation of an annual evaluation for tuberculosis.

Based on file review, the facility did not ensure that when any portion of an assisted living facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as evidenced by an initial and subsequent annual reports from the Virginia Department of Health. Evidence: An annual health inspection was not provided when requested. The licensee reported thar an annual inspection was not been secured.

Based on interviews and a review of the Virginia Department of Health Professions (DPH) website, it was determined that for a facility licensed for both residential and assisted living care the administrator was not licensed as an assisted living facility administrator or nursing home administrator by the Virginia Board of Long-Term Care Administrators pursuant to Chapter 31 (? 54.1-3100 et seq.) of Title 54.1 of the Code of Virginia. Evidence: 1. The Virginia Department of Health Professions license lookup search contained documentation that the nursing home administrator license for staff # 1 expired on 3/31/2023. 2. The manager for the facility (staff # 2) telephoned staff # 1 during the inspection and handed the telephone to the licensing inspector, staff # 1 admitted during the telephone call that her license as a nursing home administrator was expired.

Based on a review of four resident files, it was determined that the facility did not ensure that prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval following order of priority. Evidence: 1. Written approval forms were found in the records for residents #2 and resident #4. 2. Staff #1 was unable to provide documentation that written approval following the order of priority was obtained.

Based on observation and interview, it was determined that the facility did not ensure that all resident records shall be retained at the facility. Evidence: On 4/1/24, the licensing inspector asked staff #1 for the record for resident #. Staff #1 disclosed that the resident record was not on site.

Based on interview, it was determined that the facility did not ensure that they shall have, keep current and implement a written plan of medication management. Evidence 1. The Licensing Inspector requested a copy of the facility?s medication management plan from staff #1 and staff #4. 2. Both were unable to provide a copy of the facility?s medication management plan.

Based on an inspection of the facility, it was determined that the facility did not ensure that all furnishings and equipment are kept clean and in good repair. Evidence: 1. The chairs in the designated dining room were in disrepair. Several of the chairs were unsteady and could not be used for seating. Staff directed licensing staff to alternative seating. One licensing staff place her bag in one chair and the back of the chair collapsed. (Photos Taken) 2. The upstairs bathroom was locked. Staff #1 and #2 reported that the bathroom was in disrepair and that is why it is locked. 3. The glass door to the shower is missing in the downstairs bathroom. 4. The kitchen stove was dirty and had areas that were stained. (photo taken) 5. The radiator in the common area was covered with dirt. (photo taken)

Based on an observation, it was determined that the facility did not ensure that ordinary materials that may be harmful to a resident with a serious cognitive impairment shall be inaccessible to residents. Evidence: The licensing inspector observed in the dining room a container of laundry detergent, a can of paint, old medications in a grocery bag, and a bag of electrical cords, etc. (photos taken)

Based on a review of four resident files, it was determined that the facility did not ensure that residents placed in the safe, secure environment shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth of Virginia or by an independent physician as having a serious cognitive impairment due to a primary diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Assessments were not found in the files for resident #2 (admitted 3/31/23) and resident # 4 (admitted 9/1/22) 2. Staff #1 reviewed the records for resident #2 and resident #4 and was unable to provide documentation that the required assessment was completed.

Based on an observation, it was determined that the facility did not ensure that bed linens are changed every seven days or more often if needed. Evidence: During an inspection of the building accompanied by staff # 2, licensing staff and staff # 2 observed, in the resident bedrooms located at the top of stairs on the left side, bed linens stained with urine and dirt that had not been changed. (photo taken)

Based on an inspection of the medication stored at the facility, it was determined that the facility did not ensure that medication was discontinued by the facility without a valid order from the physician or other prescriber. Evidence: 1. Triamcinolone 1% was listed on the medication administration record as a medication for resident #1, Triamcinolone was not in the medication cart. 2. Staff #1 reported that the medication had been discontinued. When asked for a physician?s order, the facility manager reported that the facility did not have a physician?s order authorizing the discontinuation of the medication.

Based on observation and interview, it was determined that the facility did not ensure that at all times the department's representative is afforded reasonable opportunity to inspect all of the facility's books, and records as specified in ? 63.2-1706 of the Code of Virginia. Evidence: 1. Licensing staff requested staff and resident files. 2. Staff #1 reported that the files were not available for review as she ?left the key at home?.

Based on an observation, it was determined that the facility did not ensure that the common sink in the downstairs bathroom have paper towels or an air dryer or liquid soap for hand washing. Evidence: Licensing staff observed that the common sink in the downstairs bathroom did not have paper towels, air dryer nor liquid soap.

Based on an inspection of the facility it was determined that the facility did not ensure that the interior of the facility is kept clean and free of rubbish. Evidence: 1. The floors and walls throughout the facility were stained with dirt. (photo taken) 2. Trash and debris was observed on the floors in three resident bedrooms. (photo/video taken) 3. The designated dining room, which is also used as the medication storage area, was cluttered - multiple storage crates, a box full of electrical cords, a bag of old medications, containers of food, broken lamps, boxes of documents, papers, etc.

Based on a review of four resident files, it was determined that the facility did not ensure that the individualized service plan was signed by the license/administrator or his designee or by the resident or his legal representative Evidence: 1.The service plans for residents #1, #2, #3 and #4 were not signed by the license/administrator or his designee or by the resident or his legal representative. 2. Staff #1 reviewed the service plans for residents #1, #2, #3 and #4 was unable to provide documentation during the inspection that the license/administrator or his designee or by the resident or his legal representative had signed the service plans.

Based on a review of four resident files, it was determined that the facility did not ensure that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator or designee shall perform a review of the appropriateness of each resident?s continued residence in the special care unit. Evidence: 1. A six-month review was not documented in the file of resident #2, who was admitted to the special care unit on 3/31/23. 2. An annual review was not documented in the files of resident #1, admitted to the special care unit on 9/12/22; resident #4, admitted to the special care unit on 9/1/22; and resident #3. admitted to the special care unit on 11/22/19.

Based on an observation, it was determined that the facility did not ensure that the facility has a secure outdoor area for the resident use. Evidence: 1. The secure outdoor area is not accessible for the residents in care. 2. Licensing staff observed the following items on the back porch: clothing, multiple trash bags of clothing, bed linen, trash, pillows. (photo taken)

Based on an inspection of the facility, it was determined that the facility did not ensure that all bedrooms contain required furnishings. Evidence: During an inspection of the building accompanied by staff #2, licensing staff observed that two resident bedrooms did not have a bedside table and lamp or bedside light accessible to the resident.

Based on observation and two inspections, the facility does not maintain two staff in the building, one of whom is readily available to assist with emergencies in the special care environment. Evidence: 1. When licensing staff arrived on 12/4/23, staff #2 was working alone in the facility. Staff #1 arrived at the facility after the inspection had started and reported that she was on leave. 3. When licensing staff arrived at the facility on 12/6/23, staff #3 was working alone in the facility. Staff #1 arrived shortly after the inspection started with resident and staff files. 4. On 12/6/23 staff #3 left the building at 11:30 am and was absent for the remainder of the inspection, leaving staff #1 as the only staff on site.

Based on observation and interview, it was determined that facility did not ensure that all staff records shall be retained at the facility. Evidence: On 12/6/23, the licensing inspector asked staff #1 for the staff records. Staff #1 disclosed that the staff records are stored at the facility located next door.

Based on an observation, it was determined that the facility did not ensure that snacks are made available at all times for all residents. Evidence: 1. Around 9:30 am on 12/6/23 resident #1 stated ?I want breakfast, something to eat?. 2. Staff #3 responded to resident #1?It isn?t 12 o?clock, look at the clock?. 3. Resident was not offered or given anything to eat by staff #3.

Based on a review of four resident files, it was determined that the facility did not ensure that the rights and responsibilities of residents in assisted living facilities were not reviewed annually with each resident or his legal representative or responsible individual. Evidence: 1. Documentation of an annual review of the rights and responsibilities of residents in assisted living facilities was not found during a review of the files for residents #1, #3 and #4. 2. Staff #1 reviewed the records for residents #1, #3, and #4, and was unable to provide documentation during the inspection that the annual review of the rights and responsibilities of residents in assisted living facilities was completed.

Based on observation, it was determined that the facility did not ensure that staff shall regularly encourage residents to participate in activities and provide guidance and assistance as needed. Evidence: 1. Licensing staff did not observe any activities or encouragement of residents to participate in activities during inspection visits on 12/4/23 and 12/6/23. 2. Two residents were observed in bed on 12/4/23 on the 2nd floor and never came downstairs. 3. Two residents were observed in the common area on both days with the TV on. 4. One was observed to be asleep in a chair. (photo taken)

Based on an observation, it was determined that the facility did not ensure that one staff member is awake and on duty at all times in each building when at least one resident is present. Evidence: 1. On 12/6/23 a licensing representative observed the only staff working in the building (staff #2) leave the building and go to the sister facility which is located next door. 2. Four residents with cognitive impairments were left unsupervised in the safe, secure building. 3. The front door was observed to be unlock and wide open.

Based on an inspection of the building, it was determined that the facility did not ensure that the building is free of foul, stale, and musty odors. Evidence: The bedroom on the 2nd floor to the left of the stairs had a strong urine odor.

Based on an inspection of the medication cart, it was determined that the facility did not ensure that medication ordered for PRN

Based on an inspection of the medication stored at the facility, it was determined that the facility did not ensure that the individual responsible for medication administration shall keep the keys to the storage area on his person. Evidence: On 12/4/23, licensing staff observed staff #2 with the keys to the medication cart. Staff #2 is not authorized by 54.1-3408 of the Virginia Drug Control Act to administer medications.

Based on a review of four resident files, it was determined that the facility did not ensure that for residents who meet the criteria for assisted living care the licensed health care professional shall provide health care oversight at least every three months. Evidence: 1. Health care oversight was not documented for the year in the files for residents #1, # 2, # 3 and # 4. 2. Staff #1 reviewed the records for residents #1, # 2, # 3 and # 4 and was unable to provide documentation during the inspection that health care oversight was completed for the residents at least every three months.

Based on a review of four resident files and interview, it was determined that the facility did not ensure that all residents shall be assessed face-to-face using the uniform assessment instrument in accordance with the Assessment in Assisted Living Facilities (22VA30-110) Evidence: 1. Resident #1 was admitted to the facility on 9/12/22. A completed UAI

Based on a review of four resident files, it was determined that the facility did not ensure, within 30 days prior to the date of admission, that a physical examination and tuberculosis screening was completed. Evidence: 1. The documented admission date for resident #4 is 9/1/22. The physical examination and tuberculosis screening was completed in June 2022, more than 30 days prior to admission. 2. Staff #1 reviewed the record for resident # 4 and unable to provide documentation during the inspection that the physical examination and tuberculosis screening was completed more than 30 days prior to admission.

Based on a review of the medication being stored at the facility, it was determined that the facility did not ensure that a medication cabinet, container, or compartment shall be used for storage of medications when such medications are administered by the facility. Evidence: 1. Licensing staff observed bubble packs of medication for resident #1 (5 medications), resident #3 (5 medications), and resident #4 (6 medications) in a grocery bag in the dining area at the facility. 2. The medication was from the months of March 2023, August 2023, and September 2023. 3. The medication was not locked and could be accessed by the residents.

Based on a review of four resident files, it was determined that the facility did not ensure that prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval following order of priority. Evidence: 1. Written approval forms were not found in the records for residents #2 and resident #4. 2. Staff #1 reviewed the records for resident #2 and resident #4 and was unable to provide documentation that written approval was received.

Based on observation and interview, it was determined that the facility did not ensure that all resident records shall be retained at the facility. Evidence: On 12/6/23, the licensing inspector asked staff #1 for resident records. Staff #1 disclosed that the resident records are stored at the facility located next door.

Based on an observation at the facility and interview with staff on 10-24-22, the facility has not developed and implemented a procedure for posting the name of the current on-site person in charge. Evidence: A posting of the on-site person in charge was not observed on the date of the inspection.

Based on a review of two staff files, the results of an initial risk assessment, documenting the absence of tuberculosis in a communicable form, was not obtained for one staff on or within seven days prior to the first day of work at the facility. Evidence: A file review found a documented start date of employment for staff # 2 of 1/31/22. The risk assessment on file was dated 9/6/22.

Based on a review of two resident files, the individualized service plan for one resident was not signed or dated by the resident?s responsible party. Evidence: A file review found no documentation to support that the service plan for resident # 1 had been reviewed, signed or dated by the resident?s responsible party.

Based on a review of the staff scheduled submitted, the facility has failed to maintain at least two direct care staff members who are awake and on duty in the special care environment. Evidence: The staff schedule for October 17, 2021 to October 31 was submitted for review. The schedule documented one staff on duty on the 7am to 7pm shift on 10/18, 10/19, 10/21, 10/22, 10/23, 10/24, 10/25, 10/26, 10/28, 10, 29, 10, 30 and 10/31. This violation was cited previously and has not been corrected.

Based on a review of two residents files, the facility failed to document that the order of priority specified in subsection A of this section was followed for one resident. Evidence: The facility has been cited previously for failure to document that the order of priority was followed for resident # 1. The violation has not been corrected as documentation of the order of priority for resident # 1 is still not documented on the resident's Approval for Placement form. .

Based on a review of uniform assessment instruments ( UAI