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: Nov. 28, 2023 and Nov. 30, 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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

22VAC40-61-150 22VAC40-61-190 22VAC40-61-230 22VAC40-61-530

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: 11/28/2023 and 11/30/2023. 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: 1 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-E
Description:	Based on record review, the center failed to review the rights and responsibilities of participants annually with each participant, or, if a participant is unable to fully understand and exercise his rights and responsibilities, the annual review shall include his family member or his legal representative. Evidence: 1. Participant #1 did not have evidence of an annual review of rights and responsibilities of participants in their participant record.
Plan of Correction:	Evidence of annual review of rights and responsibilities of participants have been added to record.
Standard #:	22VAC40-61-220-D
Description:	Based on record review, the center failed to ensure the written assessment of a participant include a description of the participant?s identified needs. Evidence: 1. Participant #1 (dated 11/9/23) did not include a description on what kind of help is needed for their identified needs in bathing, dressing, and bowel and bladder incontinence.
Plan of Correction:	Description of what type of individual needs and supports were added to assessment such as monitoring and supervision with using the bathroom and supervision while consuming food to prevent choking hazard.
Standard #:	22VAC40-61-230-F
Description:	Based on record review, the center failed to ensure the participant, family member, or legal representative sign the plan of care. Evidence: 1. Participant #1?s plan of care (dated 11/13/2023) is not dated nor signed by the participant, family member, or legal representative.
Plan of Correction:	Participant plan of care was signed by Guardian.
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. Participant #1 (admitted 11/13/2023) did not have a signed written agreement between the participant and the center in their record.
Plan of Correction:	Participant agreement was signed by Guardian.
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. The physical examination to include an assessment for tuberculosis by a licensed physician (dated 02/22/2023) for Participant #1 (admitted 11/13/2023) was completed on 03/29/2023.
Plan of Correction:	Letters signed by Physician that physical is in good standing.
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 hire for each employee. Evidence: 1. The center did not obtain a completed criminal history record report for Staff #1 and Staff #2 on or prior to the 30th day of hire.
Plan of Correction:	Background check have been sent off to the state police.