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: Donesia Peoples (757) 353-0430

Inspection Date: Dec. 4, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Comments:

Type of inspection: Monitoring An unannounced monitoring inspection took place on 12/04/2024 at 9:30 am to 12:18 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 12 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: A tour of the center was completed to include outside and inside of the grounds. Lunch was observed and the facility?s fire drill logs were reviewed. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-61-50-E
Description:	Based on the record review the center failed to ensure the rights and responsibilities of participants shall be reviewed annually with each participant. Evidence: 1.The record for resident #1 did not contain an annual review of the rights and responsibilities of residents completed after the last review dated 07/07/23.
Plan of Correction:	Resident #1 responsible party signed new rights and responsibilities form. All current residents reviewed. Implementing reviews after start of every new calendar year moving forward. (First business day after holiday closures).
Standard #:	22VAC40-61-190-A
Description:	Based on the onsite observation and staff interview the center failed to ensure during the center?s hours of operation, one staff person on the premises shall be in charge of administration of the center. The person shall be either the director or a staff member appointed by the licensee or designated by the director. Evidence: 1. During the Licensing Inspector (LI) arrival at the center at 9:30 am, the center?s director or a designated staff person in charge was not on site at the facility. 2. During an interview with staff #2, staff #2 stated staff #3 was the person in charge of the center, however staff #3 was not onsite at the center at the time of the LI arrival.
Plan of Correction:	As per the LPN?s Job Description, they are designated as the individual in charge of the facility in the director?s absence. To accommodate for any unforeseen circumstances such as emergencies, traffic, etc. additional employees have been designated as staff in charge which are as follows: ADS Assistant Director; Clinical Supervisor/LPN; Administrative Assistant
Standard #:	22VAC40-61-230-F
Description:	Based on the record review the center failed to ensure the preliminary plan of care any updated plans shall be in writing and completed, signed, and dated by the staff person identified in subsection B of this section. The participant, family member, or legal representative shall also sign the plan of care. The plan shall indicate any other individual who contributed to the development of the plan with a notation of the date of contribution. Evidence: 1. The record for resident #1 contains a plan of care updated 8/05/24. The updated plan of care did not include the signature and date of the participant, family member, or legal representative.
Plan of Correction:	LPN contacted family members of resident #1, and updated plan of care was sent to be signed.
Standard #:	22VAC40-61-300-A
Description:	Based on review of the medication storage area the center failed to implement a plan for medication management. Evidence: 1. The facility?s medication management plan includes: ?medications that are expired, discontinued, or no longer needed will be identified during regular medication reviews. These medications will be securely stored in a locked area separate from regularly administered medications until disposal.? Resident?s #1 Amlodipine medication expired, 10/11/24 and was located inside the medication storage area. Staff # 4 confirmed resident #1 was administered the Amlodipine medication after the expiration date of 10/11/24. 2. Resident?s #1 Medication administration record documented the resident received Amlodipine after the date of 10/11/24.
Plan of Correction:	Separate storage area for expired medication has been designated and expired meds shall only be kept on site for a maximum of 7 business days. All expired medications have been returned to the family for resident # 1, as per our MMP. Medication for participants was reviewed, and all current medications administered are up to date, and corrected with staff # 4.