VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Living Well Assisted Living
2600 Shorehaven Drive
Virginia beach, VA 23454
(757) 690-2744

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: March 23, 2023 and March 30, 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

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: 3/22/2023 from 8:55 am to 3:30 pm. A second day of inspection was attempted on 03/30/2023. 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: 5 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 5 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 #:	22VAC40-73-1030-B
Description:	Based on record review, the facility failed to ensure within four months of the starting date of employment, direct care staff attend six hours of training in working with individuals who have a cognitive impairment, and the training shall meet the requirements of subsection C of this section. Evidence: 1. During the onsite inspection, Staff #1 and Staff #2 were unable to provide evidence of the required six hours of training in working with individuals who have a cognitive impairment within four months of the starting date of employment and licensure (11/9/2023) for Staff #3 (hired 11/17/2022) and Staff #5 (hired prior to licensure).
Plan of Correction:	There was no proof of the required 6 hours of training for Staff #3 and Staff #5. All staff have the ability to be affected. The Executive Director and the Program Director will ensure all staff have the required 6 hours of training within four months of their start date. The Executive Director will audit staff records for 3 months to ensure compliance.
Standard #:	22VAC40-73-1070-B
Description:	Based on observation and interview, the facility failed to ensure ordinary materials or objects that may be harmful to a resident with a serious cognitive impairment, these materials or objects be inaccessible to the resident except under staff supervision. Evidence: 1. During the onsite inspection, shelves were noted outside the kitchen area in a resident hallway and contained a jug of vegetable oil and the staff member?s personal belongings (purse, water bottle, lunch, etc.). 2. Staff #1 and Staff #2 acknowledged the potential of these ordinary materials or objects may be harmful to a resident with a serious cognitive impairment and were accessible to residents without staff supervision.
Plan of Correction:	Shelves outside the kitchen door contained objects possibly harmful to a resident with serious cognitive impairment. The Executive Director and the owner will ensure the shelves are not used to hold harmful materials. Checks of the contents of the shelves will be checked at least 3 times a week by program director and owner.
Standard #:	22VAC40-73-70-A
Description:	Based on record review, the facility failed to ensure any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident to the regional licensing office within 24 hours. Evidence: 1. During a review of Resident #2?s record, it was noted that on 2/1/23 Resident #2 fell out of bed, sustained a laceration to the back of the head, and was sent to the ER. The resident received stitches to the back of the head and returned to the facility. The assigned licensing inspector did not receive a notification of the incident.
Plan of Correction:	All residents have the ability to be affected. All staff (including temporary staff) will be in-serviced on incident reporting expectations-including to notify Executive Director of falls and transfers to the ER. All incident reports will be reviewed timely. Incident log will be created and audited. Owner or designee will audit log for mandatory reporting compliance. Log will be monitored for 3 months for compliance and discussed during risk management meeting.
Standard #:	22VAC40-73-250-C
Description:	Based on record review, the facility failed to maintain personal and social data on staff to include verification that the staff person has received a copy of his current job description. Evidence: 1. Staff #3?s record does not include verification that the staff person has received a copy of their current job description.
Plan of Correction:	Staff #3 has reviewed and signed job description with Owner. All staff have the ability to be affected. All employee personnel files will be audited signed job descriptions. Executive Director will submit results to Owner. Owner or designee will audit all new employee files for compliance for 3 months. Results will be discussed during risk management meeting.
Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure health information required by these standards be maintained at the facility and be included in the staff record for each staff person, and shall be maintained at the facility for each household member who comes in contact with residents. Evidence: 1. Staff #1 was unable to provide the results of a TB risk assessment for Staff #6.
Plan of Correction:	TB Risk assessment has been received for staff #6. All staff have the ability to be affected. 100% audit will be completed on tb skin test/ risk assessment compliance. TB skin test or risk assessment will be obtained for any staff that does not have tb skin test/risk assessment on file. All new employees will be audited for compliance by Executive Director or designee for 3 months . Results will be given to Owner and discussed during risk management meeting.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to 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 #3 (hire date 11/17/22) works as direct care staff and does not have documentation of a current certification in first aid in their staff record.
Plan of Correction:	Staff#3 has been scheduled to attend a first aid class. All staff have the ability to be affected. 100% audit of all personnel files will be completed. Any staff not having first aid will be asked to attend first aid class. Executive Director will manage new hire log for all new employees. Owner or designee will audit log for 3 months. Results discussed during risk management meeting.
Standard #:	22VAC40-73-290-B
Description:	Based on observation and discussion, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge, as provided for in this chapter, in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. Upon entry on 03/23/2023, the signage of the manager on duty was blank and did not indicate the designated person in charge. Staff #4, Staff #5, and Staff #6 verbally stated Staff #6 was the designated person in charge; however, later Staff #1 stated Staff #4 was the designated person in charge at the time of the initiation of the inspection. 2. On 03/23/2023, Staff #1 acknowledged the current on-site person in charge was no posted in a place in the facility that is conspicuous to the residents and the public. 3. On the follow-up visit on 03/30/2023, the signage of the manager on duty was blank and did not indicate the designated person in charge.
Plan of Correction:	Posting of person in charge has been posted. In-service with staff and management will be completed concerning posting and who is in charge. Executive Director or designee will randomly audit posting for placement at least twice a week. Results will be given to owner and discussed at risk management meeting for 3 months.
Standard #:	22VAC40-73-300-B
Description:	Based on interview, the facility failed to ensure a method of written communication be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. Evidence: 1. During the onsite inspection, Staff #1, Staff #5, and Staff #6 were unable to provide a method of written communication as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions.
Plan of Correction:	A 24 hour communication book will be implemented. All employees have the ability to be affected. All staff will be in-serviced on the communication book. Communication book expectations and use will be added to new employee orientation. Communication book will be reviewed by management and audited at least 3 times a week. Results will be discussed among management, variances will be discussed at risk management meeting.
Standard #:	22VAC40-73-310-D
Description:	Based on record review, the facility failed to provide written assurance to a resident or the legal representative documenting that the facility has the appropriate license to meet their care needs at the time of admission. Evidence: 1. During the onsite inspection, there was no evidence of written assurance for Resident #1 (admitted 3/21/2023) or their legal representatives documenting that the facility has the appropriate license to meet their care needs at the time of admission.
Plan of Correction:	Written assurance for resident #1 has been completed. All new admissions have the ability to affected. Owner and Program Director will be in-serviced on Admission Process and importance of written assurance. 100% audit will be completed on all resident files. New admissions will be audited by Program Director. Results will be given to Executive Director and discussed during risk management meeting.
Standard #:	22VAC40-73-440-B
Description:	Based on record review, the facility failed to ensure for private pay individuals, the administrator or the administrator's designated representative approves and then signs the completed UAI. Evidence: 1. Based on record review, the UAI completed on 3/15/23 for Resident #1 was not approved and signed by the administrator or the administrator?s designated representative.
Plan of Correction:	UAI for Resident #1 has been approved and signed by Executive Director. All residents have the ability to be affected. Owner and Program Director will be in-serviced on the admission process and UAI standards. 100% audit will be completed on all UAI. Program Director will audit UAIs weekly for 3 months. Results will be discussed at risk management meeting.
Standard #:	22VAC40-73-450-A
Description:	Based on record review and discussion, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: 1. During the onsite inspection, Resident #1?s record did not contain a preliminary plan of care. 2. Staff #1 acknowledged Resident #1 (admitted 3/21/23) did not have a preliminary plan of care.
Plan of Correction:	Resident #1?s record did not contain a preliminary plan of care. All residents have the ability to be affected. Owner and Program Director will be in-serviced on Admission Process and importance of ISPs. Owner and Executive Director will ensure ISPs are completed and signed before each new resident moves into the facility.
Standard #:	22VAC40-73-550-G
Description:	Based on record review, the facility failed to annually review the rights and responsibilities of residents with each staff person. Evidence: 1. Staff #5?s record did not include written acknowledgement of having been so informed of the review of the rights and responsibilities of residents within the last year as the last review was completed on 12/23/2021.
Plan of Correction:	Staff #5?s record did not include written acknowledgement of having been informed of the review of the rights and responsibilities of the residents within the last year. All residents and staff have the ability to be affected. Owner and Program Director will schedule and execute training on Resident Rights for all employees.
Standard #:	22VAC40-73-560-E
Description:	Based on observation, the facility failed to ensure all resident records be kept in a locked area. Evidence: 1. Upon entry and during the tour of the facility, the area where resident records are stored was open, unlocked, unattended, and accessible.
Plan of Correction:	The facility failed to ensure resident records be kept in a locked area. The owner, Executive Director and Program Director will lock the office door when stepping away from their desk.
Standard #:	22VAC40-73-560-I
Description:	Based on record review, the facility failed to ensure a current picture of each resident be readily available for identification purposes or, if the resident refuses to consent to a picture, there be a narrative physical description, which is annually updated, maintained in his file. Evidence: 1. Resident #1?s record did not include a current picture or a narrative physical description in their resident record.
Plan of Correction:	The facility failed to ensure a current picture of each resident to be readily available for identification purposes. All residents have the ability to be affected. Owner will ensure all resident records include a picture before or day of move-in of a new resident.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, record review, and interview, the facility failed to implement their written plan for medication management to include methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. Evidence: 1. While ensuring accurate counts of all controlled substances with Staff #6, it was discovered that the count indicated on the Controlled Drug Record was not consistent with the amount of medication for Resident #3?s Lorazepam .5 mg tablets with 11 noted on the record as available with 10 tablets on the medication cart and Resident #4?s Gabapentin 100 mg capsule with 47 noted on the record as available with 46 capsules on the medication cart. 2. Staff #1 and Staff #6 acknowledged the Controlled Drug Record was not consistent with the amount of two medications identified on the medication cart.
Plan of Correction:	Facility failed to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes occur. All residents have the ability to be affected. Owner will institute new eMar software that includes electronic controlled substance count to ensure an accurate count whenever assigned medication administration staff changes occur. Owner or designee will do a check for accuracy of controlled substance count for 3 months.
Standard #:	22VAC40-73-650-B
Description:	Based on record review and discussion, the facility failed to ensure physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements identify the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. Resident #1 admitted on 3/21/23, and their admitting physician orders (11 total) did not identify the diagnosis, condition, or specific indications for administering each drug.
Plan of Correction:	Resident #1, admitted on 3/21/23 and their admitting physician orders did not identify the diagnosis, condition or specific indications for administration of each drug. All residents have the ability to be affected. Owner will ensure orders are reviewed before admittance of any new residents to ensure the diagnosis, condition or specific indications are evident for administering each drug.
Standard #:	22VAC40-73-660-A-3
Description:	Based on observation, the facility failed to ensure the medication cart be locked and the individual responsible for medication administration keep the keys to the storage area on their person. Evidence: 1. During a tour of the facility, the medication cart was observed to be unlocked and unattended with the keys noted on the cart and not on the individual responsible for medication administration.
Plan of Correction:	The facility failed to ensure the medication cart be locked and the individual responsible for the keys to the storage area be on their person. All residents have the ability to be affected. The owner and program director will conduct a training with all RMAs for compliance to this standard.
Standard #:	22VAC40-73-680-I
Description:	Based on record review and interview, the facility failed to ensure the MAR include the items required in the standard. Evidence: 1. The MAR did not include the following for Resident #1: date prescribed, diagnosis, condition, or specific indications for administering the drug or supplement, and name, signature, and initials of all staff administering medications. 2. During a medication observation with Staff #6, the document that was being utilized as the MAR for Resident #1 were the physician order sheets for Resident #2 (one sheet) and Resident #3 (one sheet). The medications, date of birth, and names of Resident #2 and Resident #3 were marked thru, but still legible. The physician orders sheets included all other personal information of Resident #2 and Resident #3 to include their allergies, diagnoses, room number, and Medicare Number, and not information pertaining to Resident #1. 3. Staff #1 and Staff #6 acknowledged the MAR being utilized to document medication administration of Resident #1 contained other resident information and did not include all of the required MAR items in the standard.
Plan of Correction:	The facility failed to have the correct MAR for resident #1. All residents have the ability to be affected. Owner will ensure that medication record is sent to the pharmacy in advance of admission and that the record is in the eMar before any new resident moves in.
Standard #:	22VAC40-90-40-E
Description:	Based on record review and interview, the facility failed to ensure criminal history record reports be kept confidential. Reports on employees shall only be received by the facility administrator, licensee, board president, or their designee. Evidence: 1. The records of Staff #3 and Staff #4 indicate the criminal history record reports were not completed by the facility administrator or licensee. 2. Staff #1 acknowledged the criminal history record reports were completed by a separate organization/entity that is not owned nor operated by the facility.
Plan of Correction:	The facility failed to ensure criminal history record reports be kept confidential. Staff #3 and Staff #4 criminal history record reports were not completed by the facility administrator or licensee. All staff have the ability to be affected. The owner or Executive Director will send criminal history checks directly to the Virginia State Police.
Standard #:	22VAC40-90-50-A
Description:	Based on record review, the facility failed to ensure when the facility utilizes temporary agencies for the provision of substitute staff to maintain a letter from the agency contain information listed in the standard. Evidence: 1. The records of Staff #6 and Staff #7 indicate the background checks are not completed by the Virginia State Police.
Plan of Correction:	The records of Staff #6 and Staff #7 background checks were not completed by the Virginia State Police. All staff have the ability to be affected. The owner or the Executive Director will send agency staff background checks to the Virginia State Police.