VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Metro Gardens Assisted Living Facility
17 Shore Street
Petersburg, VA 23803
(804) 732-1813

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: Feb. 9, 2022 , Feb. 11, 2022 and Feb. 22, 2022

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 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 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. 22VAC40-80 THE LICENSING PROCESS.

Comments:

An unannounced monitoring inspection was conducted on the following dates: February 09, 2022, February 11, 2022, and February 22, 2022 for Metro Gardens Assisted Living Facility. One out of three inspection visits, the facility failed to have an active infection control surveillance monitoring policy for visitors, staff members, and residents. The facility administration team reported the census as twenty (20) residents in care. Residents were observed during daily activities and direct care staff members were observed providing resident centered services. The sample size consisted of four (4) resident records and three (3) new staff records. Medication audit and meals were observed during the building tour. Also during the renewal study, interviews were conducted with several staff members and residents. Areas of non-compliance were cited in the violation notice. You can contact the assigned inspector at (804) 662-9432 or send an email to Vashti. Colson @dss.virginia.gov to discuss any questions you may have. Thank you for your cooperation.

Violations:

Standard #:	22VAC40-73-100-B
Description:	VIOLATION: The facility failed to make the infection control applicable to each staff member or each volunteer and as well as the entire premises. EVIDENCE: Upon entering the facility on February 09, 2022, the licensing inspector noted that the facility failed to have an identified staff member to provide surveillance of the facility's visitors concerning temperatures, tracking guests/visitors, or providing protective equipment. During the first renewal visit, it was noted that the designated staff member on duty and several residents in care were sitting in the upstairs lobby area without wearing protective equipment.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-660-A-1
Description:	VIOLATION: Based upon observation, and photos taken during the renewal inspection, the facility failed to keep the medication storage area locked. EVIDENCE: Upon entering the medication room the inspector noted that the shared Dutch door window between the medication room and the dining room was open. A couple of inches below the Dutch door window was a large open brown box ,located on the medication room floor, filled with bubble packs of medications. Also laying on the table near the medication cart was a bottle of liquid medication and two empty bubble packages. The licensing inspector documented a small sample of the listed medications that were left in the unlocked medication room: 1) Vitamin B-12 1,000 MCG 2) Vitamin D3 2000 3) Baclofen 10 MG 4) Benztropine MES 1 MG 5) Ziprasidone HCL 60 MG CAP 6) Ferrous Sulfate 325 MG 7) Potassium CL 20 MEQ ER 8) Vitamin D3 50 MCG (2,000) 9) Lisinopril 5 MG 10) Sertraline HCL 25 MG 11) Vitamin D2 1.25 MG (50,000 UN MG-1) 12) Aspirin 81 MG Chewable tablet 13) Trazodone 100 MG 14) Fluoxetine HCL 40MG 15) Olanzapine 15 MG 16) Docusate CAL 240 MG 17) Buspirone HCL 10 MG 18) Amlodipine Besylate 2.5 MG 19) Metoprolol SUCC ER 25 MG 20) Multivitamin - Minerals TAB 21) Ferrous Sulfate 325 MG 22) Pravastatin Sodium 40 MG 23) Polyethylene Glycol 3350 Powder for Oral Solution
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-A
Description:	VIOLATION: Based upon the building tour observation , the facility failed to maintain the interior and exterior free from rubbish. EVIDNECE: 1) During the building tour, room #3 had an extra box spring behind the resident?s bed. Also, a twin size mattress was located in the second floor hallway across from room #3. 2) One of the ceiling panels in the dining area was hanging from the ceiling covered with a large black patterned stain.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-890-B
Description:	VIOLATION: Based upon the building tour, the facility failed to maintain adequate interior lighting throughout the building. EVIDENCE: During the building tour, the second floor fluorescent lights were dull giving off limited illumination throughout the halls.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-940-A
Description:	VIOLATION: Based upon the record review and observation, the facility failed to comply with the Virginia State Wide Fire Prevention Code (13 VAC5-51). EVIDENCE: The facility failed to have a current annual fire inspection accessible for the renewal inspection or for the inspector's review.
Plan of Correction:	Not available online. Contact Inspector for more information.