VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Parsons Residential Care Center
1005 Deep Creek Boulevard
Chesapeake, VA 23323
(757) 487-0487

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Sept. 28, 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 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

Technical Assistance:

Personal Data Form

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: An unannounced renewal inspection took place on 09/28/2023 from 8:30 am to 5:10 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: 28 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: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Lunch were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, resident fire and resident emergency drills, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. 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 #:	22VAC40-73-210-B
Description:	Based on the record review the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. Evidence: 1. The record for Staff #1(Personal Care Aide), hire date 08/30/22, contained documentation of only 4 hours of annual training.
Plan of Correction:	Executive Director, Director of Nursing or Business Office Manager will not put new hires on schedule until all mandatory in-services required within first 30-days are completed. Tracking tickler of continued training will be monitored by the Business Office Manager. Executive Director will periodically review tickler.
Standard #:	22VAC40-73-250-D
Description:	Based on the record review the facility failed to ensure each staff person on or within 7 days prior to the first day of work at the facility shall submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as evidence by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Evidence: 1. The record for staff #3, first day of work on 07/10/23, contains a risk assessment for TB dated 05/24/23, which is more than 30 days prior to the staff?s first day of work.
Plan of Correction:	Business Office Manager will ensure TB risk assessments for new hires be collected on or within 7 days prior to the first day of work documenting the new hire is free of tuberculosis. Risk assessment shall be 30-days current and put into the Associate file. A tracking tickler will be monitored by the Business Office Manager. Executive Director will periodically review tickler.
Standard #:	22VAC40-73-320-B
Description:	Based on the record review the facility failed to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident. Evidence: 1. The record for resident #3 contains a risk assessment for TB dated 03/24/22. The record does not contain documentation of a risk assessment for TB completed annually after 03/24/22.
Plan of Correction:	Director of Nursing will make sure a risk assessment for TB is completed annually on each Resident and a tracking tickler will be reviewed periodically by the Executive Director.
Standard #:	22VAC40-73-450-F
Description:	Based on the record review the facility failed to ensure the individualized service plan (ISP) shall reviewed and updated at least once every 12 months and as needed for significant change of a resident?s condition. Evidence: 1. The record for resident #2 contains an ISP dated 03/28/22. The record did not contain an ISP completed annually after the date of 03/28/22. 2. The record for resident #2 contains a physician order dated 03/24/23 for a hospice evaluation and treatment. The resident?s record contains a hospice care plan with a start date of 04/11/23. The resident?s ISP dated 03/28/22 was not updated and reviewed for a significant change in the resident?s condition to include hospice care services.
Plan of Correction:	Director of Nursing or Designee will review & update ISP?s every 12 months and as needed for significant change in a Residents? condition. Executive Director will audit five Resident ISP?s periodically to ensure accuracy.
Standard #:	22VAC40-73-490-D
Description:	Based on review the facility failed to ensure the licensed health care professional who provided the health care oversight shall include in the health care oversight the specific residents for whom the oversight was provided must be identified. Evidence: 1. The facility?s health care oversight dated 06/08/23 did not include a list of residents for whom the oversight was provided. 2. The list of residents included in the healthcare oversight was requested and not provided during this inspection.
Plan of Correction:	Director of Nursing will ensure Healthcare Oversight includes a list of Resident charts for whom Oversight was completed on.
Standard #:	22VAC40-73-530-B
Description:	Based on observation, and staff interviews the facility failed to ensure doors leading to the outside shall not be locked from the inside or secured from the inside in any manner that amounts to a lock. Evidence: 1. Based on observation the doors leading to the outside of the facility are locked from the inside. 2. Staff # 9 acknowledged the doors leading to the outside of the facility are locked from the inside and a secure code is required to be entered into the keypad to unlock the doors and exit the facility. 3. The facility is not licensed as a safe secure unit.
Plan of Correction:	? Director of Nursing and/or Designee will perform routine audit(s) for each Resident relating to the Cognitive Impairment Form. Facility will ensure any Resident who does not have a serious cognitive impairment be allowed to freely leave the facility. Exit code will be provided to cognitively intact residents and visibly posted near exit zone(s) for residents, families and visitors. Emergency Push Exit has been installed for circumstances requiring immediate emergency exiting. The community has obtained quotes and is in the process of reviewing for installation of Tektone (Wander guard System). Executive Director will re-educate all staff on Residents Rights and safety in accordance to DSS Standard 22VAC40-73-530-B. The Executive Director will monitor for compliance.
Standard #:	22VAC40-73-680-B
Description:	Based on observation the facility failed to ensure medications shall remain in the pharmacy issued container, with the prescription label or direction labeled attached, until administered to the resident. Evidence: 1. During the medication cart observation with staff #3, located in the first drawer were two small plastic cups that contained pills. The plastic cups were not labeled, and the pills were not in a pharmacy issued container. 2. Staff #3 acknowledged, staff #3 removed the pills from the pharmacy issued container and placed the pills in the plastic cups and was waiting to locate the residents to administer the medications. Staff #3 acknowledged the pills belonged to residents # 7, and #8.
Plan of Correction:	Director of Nursing will in-service all Registered Medication Aides on proper dispensing of medications until administered to the Resident and the attendance document will be maintained in the Executive Director?s office. Executive Director & or Director of Nursing will monitor periodically.
Standard #:	22VAC40-73-950-F
Description:	Based on review the facility failed to ensure the facility shall review the emergency preparedness plan annually. Evidence: 1. The facility did not provide documentation of an annual review of the facility?s emergency preparedness plan.
Plan of Correction:	Executive Director will review annually the Emergency Preparedness Plan with all staff. Attendance will be documented and maintained in the Executive Director?s office.
Standard #:	22VAC40-73-970-E
Description:	Based on the facility record review the facility failed to ensure a record of the required fire and emergency evacuation drills shall include: the name of the person conducting the drill; the number of residents; any special conditions stimulated; weather conditions. Evidence: 1. The facility?s fire dill records dated 06/22/23, 07/22/23, and 8/28/23 did not include the name of the person conducting the drill; the number of residents participating; any special conditions stimulated; weather conditions.
Plan of Correction:	Maintenance Director will utilize the required fire drill template and fill out the necessary blocks of information. Completed form(s) will be maintained in the Executive Director?s office.
Standard #:	22VAC40-73-990-C
Description:	Based on review the facility failed to ensure at least every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years. Evidence: 1. The facility did not provide documentation of staff participation in an exercise in which the procedures for resident emergencies were practiced every 6 months.
Plan of Correction:	Executive Director will conduct an exercise every 6 months with all staff regarding procedures for Resident Emergencies and the attendance documentation will be maintained in the Executive Director?s office.
Standard #:	22VAC40-90-30-B
Description:	Based on the onsite staff record review, the facility failed to ensure a sworn statement or affirmation shall be completed for all applicants for employment. Evidence: 1. The record for staff #4, hire date 07/14/23, did not contain a sworn statement or affirmation. 2. The record for staff #5, hire date 07/01/23, did not contain a sworn statement or affirmation. 3. The record for staff #6, hire date 06/20/23, did not contain a sworn statement or affirmation. 4. Staff #8 acknowledged the records for staff #, 4, #5, and #6 did not contain a sworn statement or affirmation.
Plan of Correction:	Business Office Manager will ensure required Sworn Statement be signed and checked off the DSS checklist during the new hire process before document is entered into the employee file. An audit of all current Associate files will be conducted by the Business Office Manager for accuracy. Executive Director will review and initial all new hire files moving forward.
Standard #:	22VAC40-90-40-B
Description:	Based on the onsite record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each staff person. Evidence: 1. The record for staff #2, hire date 07/17/23, did not contain a criminal history report. 2. The record for staff #3, hire date 07/10/23, did not contain a criminal history report. 3. The record for staff #4, hire date 07/14/23, did not contain a criminal history report. 4. The record for staff #5, hire date 07/01/23, did not contain a criminal history report. 5. The record for staff #6, hire date 06/20/23, did not contain a criminal history report. 6. The record for staff #7, hire date 05/10/23, did not contain a criminal history report. 7. Staff #8 acknowledged (staff #2, #3, #4, #5, #6, #7) are currently employed with the facility and the facility did not obtain the criminal record checks on or prior to the 30th day of employment.
Plan of Correction:	Business Office Manager will ensure required Criminal Background Check be obtained on or prior to the 30th day of employment for all new hires. Upon receipt it will be checked off the DSS checklist and entered into the employee file. An audit of current Associate files will be conducted by the Business Office Manager for accuracy. Executive Director will review and initial all new hire files moving forward.