VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Skyline 21, LLC
3104 Camelot Blvd
Chesapeake, VA 23323
(757) 348-5510

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Sept. 21, 2023 and Sept. 28, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 ADMISSION, RETENTION AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUND 22VAC40-61 EMERGENCY PREPAREDNESS 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

Technical Assistance:

22VAC40-61-50 22VAC40-61-140 22VAC40-61-180 22VAC40-61-250

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: 09/21/2023 and 09/28/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of participants present at the facility at the beginning of the inspection: 0. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 2. Number of staff records reviewed: 2. Observations by licensing inspector: The following were reviewed: staff and participant records, first aid kit, and water temperature sampled. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-61-50-B
Description:	Based on observation, the center failed to ensure the rights of participants are printed in at least 14-point type and posted conspicuously in a public place in the center. Evidence: 1. During a tour of the center with Staff #1 on 09/21/2023, the rights of participants were not posted in the center.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-50-D
Description:	Based on observation, the center failed to ensure the posting of the name and telephone number of the toll-free telephone number of the Virginia Long-Term Care Ombudsman Program and any local ombudsman program servicing the area, and the toll-free telephone number of the disAbility Law Center of Virginia. Evidence: 1. During a tour of the center with Staff #1 on 09/21/2023, there was not a posting in the center that included the name and telephone number of the toll-free telephone number of the Virginia Long-Term Care Ombudsman Program and any local ombudsman program servicing the area, and the toll-free telephone number of the disAbility Law Center of Virginia.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-60-B
Description:	Based on observation, the center failed to ensure that the current license is posted in the center in a place conspicuous to the participants and the public. Evidence: 1. During a tour of the center with Staff #1 on 09/21/2023, the current license for the center was not posted.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-110-A
Description:	Based on record review and observation, the center failed to ensure prior to working directly with participants that all staff receive training identified in the standard. Evidence: 1. During an onsite inspection of the center on 09/21/2023, Staff #2 and Staff #3 did not have documentation of initial staff orientation and training in their record. 2. Staff #2 and Staff #3 were present and observed working directly with participants during the onsite inspection on 09/21/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-160-A-4
Description:	Based on record review, the center failed to ensure there is at least one staff person on the premises at all times who has current certification in first aid that meets the specifications of this section, unless the center has an on-duty registered nurse or licensed practical nurse. Evidence: 1. During an onsite inspection of the center on 09/21/2023, there was no documentation available that there was at least one staff person present with a current certification in first aid.
Plan of Correction:	Staff first Aid Documentation was added to employee file
Standard #:	22VAC40-61-160-B
Description:	Based on record review, the center failed to ensure there is at least two direct care staff on the premises at all times who have current certification in CPR 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: 1. During an onsite inspection of the center on 09/21/2023, there was no documentation available that there were at least two direct care staff present with a current certification in CPR.
Plan of Correction:	First Aide and CPR was placed in employee file
Standard #:	22VAC40-61-220-A
Description:	Based on record review, the center failed to ensure a written assessment of a participant be secured or conducted prior to or on the date of admission by the director, a staff person who meets the qualifications of the director, or a licensed health care professional employed by the center. Evidence: 1. During the onsite inspection on 09/28/2023, Participant #1 and Participant #2 (both admitted 09/06/2023) did not have an assessment in their record.
Plan of Correction:	Plan of care was completed and added to participant file
Standard #:	22VAC40-61-230-A
Description:	Based on record review, the center failed to ensure prior to or on the date of admission, a preliminary multidisciplinary plan of care based upon the assessment be developed for each participant. Evidence: 1. During the onsite inspection on 09/28/2023, Participant #1 and Participant #2 (both admitted 09/06/2023) did not have a preliminary multidisciplinary plan of care in their participant file.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-61-240-A
Description:	Based on record review, the center failed to ensure at or prior to the time of admission, there be a written agreement between the participant and the center. The agreement shall be signed and dated by the participant or legal representative and the center representative. Evidence: 1. During the onsite inspection on 09/28/2023, Participant #1 and Participant #2 (both admitted 09/06/2023) did not have a written agreement between the participant and the center in their record.
Plan of Correction:	Assessment was added to participant file
Standard #:	22VAC40-61-250-C
Description:	Based on observation and interview, the center failed to ensure participant records be retained at the center. Evidence: 1. During an onsite inspection of the center on 09/21/2023, Staff #1 acknowledged and confirmed participant records were not available or retained at the center at the time of inspection.
Plan of Correction:	Participant files were stored in file cabinet on facility premises.
Standard #:	22VAC40-61-260-A
Description:	Based on record review, the center failed to ensure within the 30 days preceding admission, a participant have a physical examination by a licensed physician. Evidence: 1. During the onsite inspection on 09/28/2023, Participant #1 and Participant #2 (both admitted 09/06/2023) did not have a physical examination to include an assessment for tuberculosis by a licensed physician in their participant file.
Plan of Correction:	Physical were requested from PCP and TB tests were screened
Standard #:	22VAC40-61-360-B
Description:	Based on observation and documentation, the center failed to ensure menus for meals and snacks for the current week are dated and posted in an area conspicuous to participants. Evidence: 1. During a tour of the center with Staff #1 on 09/21/2023, the menu for meals and snacks for the current week was not posted in the center.
Plan of Correction:	New Menus were posted
Standard #:	22VAC40-61-440-B-3
Description:	Based on observation, the center failed to ensure an area for supervised outdoor activities be equipped with appropriate seasonal outdoor furniture. Evidence: 1. During a tour of the center with Staff #1 on 09/21/2023, the area available and accessible for supervised outdoor activities was shown without any appropriate seasonal outdoor furniture.
Plan of Correction:	Outdoor Furniture installed outside
Standard #:	22VAC40-61-480-A
Description:	Based on observation and interview, the center failed to ensure the rest area be equipped with one bed, comfortable cot, or recliner for every 12 participants. Evidence: 1. During a tour of the center on 09/21/2023, Staff #1 confirmed the center does not have a bed, comfortable cot, or recliner for the rest area on-site and available at this time.
Plan of Correction:	Cots were purchase and placed at facility
Standard #:	22VAC40-61-530-B
Description:	Based on observation, the center failed to ensure a fire and emergency evacuation drawing show primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers shall be posted in a conspicuous place. Evidence: 1. During a tour of the center with Staff #1 on 09/21/2023, the fire and emergency evacuation drawings did not include primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers.
Plan of Correction:	Emergency Evacuation Drawing Posted
Standard #:	22VAC40-61-550-A
Description:	Based on observation, the center failed to ensure each building of the center and all vehicles being used to transport participants shall contain a first aid kit which shall include a list of items as identified in the standard. Evidence: 1. During an onsite inspection of the center on 09/21/2023, the first aid kit of the building did not include a disposable single-use breathing barrier or shield for use with rescue breathing or CPR, a small operable flashlight, or triangular bandage.
Plan of Correction:	Breathing Barrier added to first aid kit, and batteries placed in flashlight
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation, the center failed to ensure the findings of the most recent inspection of the center be posted on the premises of the center. Evidence: 1. During a tour of the center with on 09/21/2023, Staff #1 confirmed the findings of the most recent inspection of the center were not posted on the premises of the center.
Plan of Correction:	Posted on wall that all inspection documents are available upon request in office
Standard #:	22VAC40-90-30-B
Description:	Based on record review, the center failed to ensure a sworn statement or affirmation be completed for all applicants for employment. Evidence: 1. 1. During an onsite inspection of the center on 09/21/2023, there was no documentation available of a completed sworn disclosure statement for Staff #1.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the center failed to obtain a criminal history record report on or prior to the 30th day of attaining licensure for each employee. Evidence: 1. The center did not obtain completed criminal history record report for Staff #1 on or prior to the 30th day of attaining licensure on 06/22/2023.
Plan of Correction:	Background docs were placed in employee file.