The Haven Assisted Living @ Studley

Based on observation and an interview with staff, the facility failed to ensure the availability of a 96-hour supply of emergency drinking water. At least 48 hours of the supply must be on site at any given time, of which the facility's rotating stock may be used. Evidence: The facility did not have any emergency drinking water available on site. This was confirmed by staff.

Based on observation during a medication pass, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber?s instructions. Evidence: The physician?s orders listed on the Medication Administration Record for April 2024 for med pass Resident # 2 indicated ?Acetaminophen Extra Strength, Take 2 tablets (1000mg) by mouth at 8 am, 2 pm, and 8 pm for pain.? However, the resident was administered two 650 mg Tylenol (Acetaminophen) to equal 1300mg. Staff # 1 stated that the resident?s ?family brought the wrong one.?

Based on observation the facility failed to ensure that the findings of the most recent inspection of the facility were posted. Evidence: The facility?s most recent violation notice was not posted.

Based on observation during a tour of the facility, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. Evidence: The floor tile was damaged with several areas of missing tile. Photographic evidence was taken.

Based on observation during med pass, the facility failed to ensure that if a restraint is used, it must: 1.Be imposed in accordance with a physician's written order that specifies the condition, circumstances, and duration under which the restraint is to be used and 2.Not be ordered on a standing, blanket, or "as needed" ( PRN

Based on observation the facility failed to ensure that the exterior of the building was maintained in good repair. Evidence: The doorbell at the side door entrance that was detached and did not work, as cited during the 3-3-23 inspection, had been removed and had not been replaced by 3-5-23 as stated in the facility?s plan of correction. Photographic evidence was taken.

Based on observation the facility failed to ensure that doors leading to the outside shall have a system of security monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms. Evidence: -The facility?s census includes four residents with serious cognitive impairment. -The side door was locked from the inside with a deadbolt lock which is a safety concern in the event of a fire. Staff # 1 unlocked the door with a key. When the licensing inspector opened the door, it was determined that the door alarm was not working and had not been replaced which was previously cited during the 3-3-23 inspection. The facility failed to repair the door alarm by 3-5-23 as stated in their plan of correction. -The licensing inspector opened the front door which contained an alarm, but the alarm did not sound. Staff # 1 confirmed that the front door alarm was not working. This was also cited during the 3-3-23 inspection. The facility failed to replace the alarm by 3-5-23 as stated in their plan of correction.

Based on a tour of the facility the facility failed to ensure that bedrooms contained all required items. Evidence: -Room # 1 which contained two residents only contained one lamp. -Room # 2 which contained two residents only contained one chair, one lamp, and one table.

Based on observation the facility failed to ensure that doors leading to the outside shall have a system of security monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms. Evidence: -The facility?s census includes residents with serious cognitive impairment. -The side door was locked from the inside with a deadbolt lock which is a safety concern in the event of a fire. Staff # 1 attempted several times to unlock the door before finding the correct key. Upon unlocking the door, Staff # 1 opened the door and determined that the door alarm was not working as the base of the alarm was on the door, but the door alarm itself had been removed. -The licensing inspector opened the front door which contained an alarm, but upon opening the door, the alarm did not sound. Staff # 1 confirmed that the front door alarm was not working.

Based on observation the facility failed to ensure that the exterior of the building was maintained in good repair. Evidence: The doorbell at the side door entrance was detached and did not work. Photographic evidence was taken.

Based on a review of the facility?s first aid kit the facility failed to ensure that the first aid kit contained all required items. Evidence: -The first aid kit did not contain adhesive tape, antiseptic ointment, hand cleaner (sanitizer), scissors, or a small flashlight. -Staff # 4 stated that she would order the first aid kit supplies.

Based on a review of resident records the facility failed to ensure that the Uniform Assessment Instrument ( UAI

Based on observation the facility failed to ensure that the exterior of the building was maintained in good repair. Evidence: -The doorbell at the side door entrance was detached and did not work. Photographic evidence was taken. -Staff # 4 stated that they would have maintenance repair the doorbell.

Based on observation the facility failed to ensure that doors leading to the outside shall have a system of security monitoring of residents with serious cognitive impairments. Such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms. Evidence: -Staff # 5 stated that there are three residents at the facility with serious cognitive impairment, however, the door alarm on the side door did not sound when the licensing inspector unlocked and opened the door to check the alarm functionality on two attempts with Staff # 5 observing. -Staff # 5 pressed the alarm button above the door and it made alert sounds afterwards.

Based on observation the facility failed to ensure that it had at least a 48 hour supply of emergency drinking water on site. Evidence: -The facility did not have a supply of emergency drinking water on site. -Staff # 5 stated that the facility ?switched the big blue water jugs out and they are not here now.?

Based on a self-report from the facility, the facility failed to notify the regional licensing office within 24 hours of any major incident that negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: -The facility failed to notify the regional licensing office within 24 hours of an incident that occurred on 11-6-21 during which Resident # 1 fell from the window of her second-story room and was seriously injured, requiring hospitalization. -Staff # 1 emailed the licensing inspector on Friday, 11-12-21 requesting a call back to ?discuss something?. Licensing inspector emailed Staff # 1 to inform her that inspector was out at on an inspection and if the inspector was unable to return the call on Friday, 11-12-21, inspector would call Staff # 1 on Monday 11-15-21. On 11-15-21 the inspector called Staff # 1 and Staff # 1 then informed the inspector of an incident in which Resident # 1 was injured and hospitalized as a result of falling from the window on 11-6-21. -The regional licensing office was informed by an outside agency that Resident # 1 was found walking down the road from the facility on 11-2-21. The facility failed to notify the regional licensing office of the resident?s elopement. During the 1-25-22 on-site investigation, Staff # 2 informed licensing staff that she picked the resident up and brought her back to the facility.

Based on a tour of the facility the facility failed to ensure that there were protective devices on the bedroom windows of residents with serious cognitive impairments to prevent the windows from being opened wide enough for residents to crawl through. Evidence: -Licensing staff observed that the window in Room # 1 where a resident with cognitive impairment lives, did not contain a protective device to prevent it from being opened wide enough for a resident to crawl through. Photograph evidence was taken. -Staff # 3 stated that Resident # 1 had been sitting in the living room area and when she went to check on the resident in her room, Staff # 3 stated that she saw the resident?s feet going out of the window. -Facility staff stated that the handle to turn and open the window in the room where Resident # 1 lived was removed after the resident fell out of the window to prevent it from being opened. Photograph evidence was taken.

Based on a review of facility documentation, interviews conducted with facility staff, and information obtained from collateral contacts, the facility failed to assume general responsibility for the health, safety, and well-being of the residents. Evidence: -Staff # 3 informed licensing staff during the on-site investigation on 1-25-22 that she entered the room of Resident # 1 on 11-6-21 and saw the resident?s feet going out of the window. Staff # 3 stated that she went outside to resident and Staff # 4 called 911. Staff # 3 stated that when she went outside where the resident was laying on the ground, she observed that the resident had an open wound on her leg that was bleeding. Staff # 3 stated that she brought the resident back inside.

Based on a review of the facility documentation and interviews with staff, the facility failed to follow its written emergency response procedures addressing alerting emergency personnel and facility staff. Evidence: 1. The first bullet under the facility?s Emergency Preparedness and Response Plan for Procedure Title: Summoning Help notes ?When it is apparent that a resident is in need of medical help, The caregiver on duty will: Notify 911 emergency services.? 2. Staff #1 stated that she contacted staff #2 (live-in care staff) and that staff #2 called the office. Staff #1 and staff #2 could not recall which one called 911 but noted that the office was called prior to calling emergency services. ?Notify the Administrator? is listed as the fourth bullet in the same document.

Based on a tour of the facility the facility failed to ensure that it stored cleaning supplies and other hazardous materials in a locked area. Evidence: Licensing staff observed a bottle of Lysol all-purpose cleaner on the bathroom sink in the room that Resident # 1 formerly lived in. The resident room and bathroom were accessible to all residents in the facility, including those residents with the dementia diagnoses. Photograph evidence was taken.

Based on staff interviews and a tour of the facility, the facility failed to ensure that a signaling device is easily accessible to the resident in his bedroom or connecting bathroom that alerts the direct care staff that the resident need assistance. Evidence: Staff stated that each resident room used to have a baby monitor, but licensing staff observed that there were no baby monitors or other signaling systems in any resident rooms during a tour of the facility. Staff showed licensing staff a new baby monitor that was still in its packaging. Staff also stated that residents will sometimes ?yell for help? if they need something.

Based on a review of the facility?s Emergency Preparedness and Response Plan the facility failed to include all required components in the plan. Evidence: The facility?s Emergency Preparedness and Response Plan did not include that after the emergency the facility shall report the emergency to the regional licensing office by the next day as specified in 22VAC40-73-70.

Based on a review of facility documentation, the facility failed to ensure that it maintained a work schedule that included the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time. Evidence: 1. Facility staff provided licensing staff with a sheet with the heading "Staff Information Sheet/Monthly Schedule (including weekends) Month of November 2021 " that listed names of the administrator, manager, primary care staff, and medication aid. 2. The sheet noted "Primary Care Staff 9 a.m.- 9a.m. (live-in)" and included the names of the caregiving staff and medication aid but did not include the dates worked for each staff member. 3. This same document notes, ?When administrator and manager are not on premises person in charge is live in care staff.? Staff #1 and #2 are both live in care staff. The Monthly Schedule did not indicate which live in care staff was in charge for any day of the week for November 2021. Photograph evidence was taken.

Based on interviews with staff, the facility failed to ensure that direct care staff made rounds at least once each hour to monitor for emergencies or other unanticipated resident needs in buildings licensed to care for 19 or fewer residents under one roof, if the signaling device does not permit staff to determine the origin of the signal to include a written log showing the date and time rounds were made and the signature of the direct care staff member who made rounds. Evidence: 1. Facility staff #1 and #2 stated that they do not remain awake throughout the night. 2. The facility staff did not provide rounds logs upon request stating that they do not complete them. 3. The facility staff stated that ?residents yell for help? if they need something.

Based on a review of facility documentation the facility failed to ensure that written communication was utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. Evidence: The facility did not have communication log notes for 11-2-2021 regarding the incident that resulted in the death of Resident # 1. Facility staff stated that noted for that day could not be found during the inspection. The facility was informed that the communication log notes for 11-2-2021 could be faxed to the licensing inspector if located but it was not received and Staff # emailed the licensing inspector on 1-26-22 and stated that the facility did not have notes for that date.

Based on a review of the facility?s Addendum: Infection Control Program COVID 19 Procedure/Infection control procedure, the facility failed to implement their infection control program. Evidence: 1. The facility?s Addendum: Infection Control Program COVID 19 Procedure/Infection control procedure, states that ?Visitors are to fill out a screening questionnaire that is related to COVID exposure or susceptibility?. However, during the 01/25/2022 on-site inspection, facility staff did not have licensing staff complete a screening questionnaire nor did facility staff ask licensing staff any screening questions. 2. The same document also states, ?We ask that anyone who enters the facility to come in the front door to have temperatures checked.? Only one of three individuals that entered the facility for the inspection had a temperature taken as the staff member could not get the thermometer to work to conduct the remaining two temperature checks.

Based on a tour of the facility the facility failed to ensure that all furnishings, fixtures, and equipment, including window coverings, shall be kept clean and in good repair and condition. Evidence: Licensing staff observed that the outside of the window in Room #1 was not clean and contained cob webs and insects. Photograph evidence was taken.

Based on a review of documentation the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that negatively threatened the life, health, safety, or welfare of any resident. Evidence: 1. The licensing office became aware of an incident that occurred on 11/2/2021 that resulted in the death of Resident #1 through notification by an outside agency on 11/30/2021. 2. The facility did not report this incident to the licensing office.

Based on staff interviews the facility failed to ensure that at least one direct care staff was awake and on duty at all times in each building when at least one resident is present. Evidence: 1. When interviewed by licensing staff, Staff # 1 and Staff # 2 stated that no staff stay awake all night. 2. Staff #4 stated that they had fewer than 19 residents so they did not need to have a staff member awake at night. However, that particular standard only applies to facilities licensed as residential only.

Based on a review of facility documentation, interviews conducted with facility staff, and information obtained from collateral contacts, the facility failed to assume general responsibility for the health, safety, and well-being of the residents. Evidence: 1. On 12/7/2021, the licensing office was contacted from a collateral contact to report a suspicious death of a resident that occurred on 11/2/2021. 2. Based on information received through the collateral contact, Resident #1 was found deceased by a staff member with a piece of furniture on top of her head and throat. 3. Based on interviews with Staff #1, Staff #2, and the collateral contact, Resident #1 was found unresponsive, deceased, and cold to the touch.

450.C Based on a review of resident records the facility failed to ensure that the Individualized Service Plan ( ISP

Based on a review of resident records, the facility failed to ensure that a restraint is imposed with a physician's order that specifies the condition, circumstances, and duration under which the restraint is to be used. Evidence: According to the resident roster submitted by the facility, Resident # 1 uses a restraint. However, the physician's orders for Resident # 1 did not contain an order for a restraint.