VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heart & Soul III ALF
611 19th Street
Newport news, VA 23607
(757) 240-4282

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: Oct. 10, 2023 and Oct. 11, 2023

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

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: 10/10/2023 and 10/12/2023 The Acknowledgement of Inspection form was emailed to the facility. Number of residents present at the facility at the beginning of the inspection: 24 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 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 Alyshia E. Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on interviews with staff, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of one resident. Evidence: 1. The record for Resident # 2 contained a facility note dated 3/6/2023, which stated the resident was transported to the hospital due to having a seizure. The resident was hospitalized from 3/6/2023 through 3/14/2023. 2. Resident #2?s record contained a facility note dated 6/20/2023 which stated the resident was sent to the hospital due to swelling in her legs. The resident was hospitalized from 6/20/2023 through 7/11/2023. 3. The facility did not notify the licensing office of these incidents. 4. Staff # 2 acknowledged the facility did not notify the licensing office of the incidents.
Plan of Correction:	The facility will ensure that all residents sent out regardless of severity an incident report will be submitted within 24- hours to inspector per regulations.
Standard #:	22VAC40-73-550-F
Description:	Based on observation the facility failed to ensure that the rights and responsibilities of residents shall be printed in at least 14-point type and posted conspicuously in a public place. Evidence: 1. During a tour of the facility on 10/10/23, the licensing inspector observed that the Rights and Responsibilities of Residents were not posted. 2. Staff #1 acknowledged the Resident Rights and Responsibilities was not posted.
Plan of Correction:	This was corrected on-site on 10/10/2023. The administrator will monitor boards daily to ensure compliance with postings.
Standard #:	22VAC40-73-680-C
Description:	Based on records reviewed, the facility failed to ensure medication be administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: During the on-site inspection 10/11/23, the Licensing Inspector observed Staff #4 administer Divalproex DR 500 mg, Metformin HCL 1,000 mg at 6:12 am to Resident #7. A review of the Medication Administration Record and Physician?s orders for the resident verified the scheduled time of administration of those medication is 8:00 am.
Plan of Correction:	The supervisor of medication aid will establish a routine monitoring system to track medication administration times. Regularly review the records to identify any emerging patterns or potential issues, enabling timely intervention. We will implement a communication protocol to ensure seamless coordination among team members involved in medication administration.