VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Primeplus at M.E. Cox , Operated by Primeplus Senior Centers
644 North Lynnhaven Road
Virginia beach, VA 23452
(757) 625-5857

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

Inspection Date: Jan. 31, 2024

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:

22VAC40-61-300

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: 01/31/2024 from 9:25 am to 12:32 pm. 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: 8 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 4 Number of staff records reviewed: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 1 participant. The following were reviewed: participant and staff records, fire drills, medication area, and the first aid kit. 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 #:	22VAC40-61-160-A-1
Description:	Based on record review, the center failed ensure each direct care staff member 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: 1. Staff #2 works as direct care staff and does not have documentation of a current certification in first aid in their record.
Plan of Correction:	Staff #2 has been signed up for a CPR/First Aid Class offered by the City of Norfolk.
Standard #:	22VAC40-61-180-E-1
Description:	Based on record review, the center failed to ensure each staff person and volunteer identified in this subsection obtain an evaluation by a qualified licensed practitioner that completes an assessment for tuberculosis in a communicable form no earlier than 30 days before or no later than seven days after employment or contact with participants. Evidence: 1. Staff #2 and Staff #3 were hired on 10/30/2023; however, their assessments for tuberculosis were completed on 11/16/2023.
Plan of Correction:	Going forward, any new staff that is hired will have their tuberculosis completed no earlier than 30 days before or no later than seven days after employment or contact with participants.
Standard #:	22VAC40-61-230-E
Description:	Based on record review, the center failed to ensure the plan of care of a participant be reviewed and updated at least every six months. Evidence: 1. The last assessment for Participant #2 was completed on 6/20/2023.
Plan of Correction:	Participant #2?s care plan has been updated by Staff #1. Participant #2?s caregiver will come to the Center on 2/14/2024 to sign their care plan.
Standard #:	22VAC40-61-250-B
Description:	Based on record review, the center failed to ensure the participant record include a current photograph or narrative physical description of the participant, which shall be updated annually. Evidence: 1. The record for Participant #3 did not include a current photograph or narrative physical description of the participant.
Plan of Correction:	Participant #3?s photograph and narrative physical description was added to the participant record.
Standard #:	22VAC40-61-260-C
Description:	Based on record review, the center failed to ensure each participant submit an annual physical examination. Evidence: 1. The last physical examination in the record for Participant #1 was completed on 11/18/2022.
Plan of Correction:	Participant #1?s physical examination will be updated and put in the file on 2/14/2024 which is the earliest date Participant #1 can be seen by the Doctor.
Standard #:	22VAC40-61-300-A
Description:	Based on observation, the center failed to implement the center?s medication management plan to include procedures for proper disposal of medication. Evidence: 1. The following medication was observed in the medication area: Acetaminophen 500mg tablets expired 11/8/2023 for Participant #5.
Plan of Correction:	The expired medication was properly disposed of on 1/31/2024. The medication was replaced.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. The following staff did not have a criminal history record report completed on or prior to the 30th day of employment: Staff #1 (hired 9/26/2023) completed 11/8/2023, Staff #3 (hired 10/30/2023) completed 12/8/2023, and Staff #4 (hired 9/19/2023) completed 11/8/2023.
Plan of Correction:	Going forward the employer will obtain a criminal history record report on or prior to the 30th day of employment on all new staff.