VIRGINIA DEPARTMENT OF SOCIAL SERVICES

LAV'M Adult Residence
912 S. Battlefield Blvd.
Chesapeake, VA 23322
(757) 546-2810

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: April 18, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-90 The Criminal History Record Report

Comments:

This was an unannounced Renewal Inspection conducted by Licensing Inspectors from the Eastern Regional Office located in Norfolk, Virginia. This Inspection was conducted on 04/18/2019 ( 7:20 a.m. - 5:10 p.m.) During the inspection a medication observation was conducted, a tour of the facility and staff and resident records were reviewed including criminal background check for all new employees since last inspection that are currently employed by the facility. Licensing Inspector conducted resident's interviews. The Healthcare Oversight Report, Nutritionist Report, Emergency Evacuation Drills, Fire Inspection, Health Inspection, and Emergency Preparedness and Response Plan were reviewed during the inspections. There were 19 residents in care during the inspection. There were violations cited in the areas of Personnel, Resident Care and Related Services and Building and Grounds. Discussion During Inspection: 1. The facility to have a plan to get window screens by the next follow-up inspection. 2. Ensure that blankets are replaced once they start to wear and tear. 3. The Supplement of an inspection is not posted. 4. The heater room in the men's bathroom does not lock. 5. The bathroom wall tile has sharp areas that can be shaved down. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain 1.) Steps to correct the noncompliance with standards (s) 2.) Measure to prevent the noncompliance from occurring again; and 3.) Person (s) responsible for implementing each step and/ or monitoring any preventive measures (s). Please send your corrective plan to me in a Word Document by 05/07/2019 or sooner. Thank you.

Violations:

Standard #:	22VAC40-73-120-A
Description:	Based on observation, record review and interview the facility failed to ensure orientation and training will occur within the first seven working days of employment. Evidence: 1. Licensing Inspector ( LI) reviewed staff's records with staff # 2 which revealed that staff # 4 ( hired on 12/13/2018) and staff # 5 hired on (12/10/2018) did not have documentation in records that orientation and training occurred within seven days of working. 2. Staff # 2 acknowledged the missing information in the staff's records.
Plan of Correction:	All new staff shall be trained in the area within the first seven ( 7) days of employment and will be under the sight supervision of a trained direct care staff personnel or administered, prior to assuming their job responsibilities.
Standard #:	22VAC40-73-550-G
Description:	Based on record review and interview the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities is reviewed annually with each staff person. Evidence: 1. Licensing Inspector (LI) reviewed staff records with staff # 2 which revealed that staff # 4 ( hired on 12/13/2018) and # 5 ( hired on 12/10/2018) did not have signed resident's rights. 2. Staff # 2 acknowledged the missing resident's rights for staff # 4 and # 5.
Plan of Correction:	Administrator and designee assures that all staff and residents will read the residents' rights and responsibilities in assisted living facility. Administrator and designee assure that staff #4 and staff #5 already read and sign the rights and responsibilities of the residents. All employees and residents will read the rights and responsibilities once a year to update their records.
Standard #:	22VAC40-73-680-B
Description:	Based on observation, record review and interviews the facility failed to ensure medications remain in the pharmacy issued container, with the prescription label or direction attached until administered to the residents. Evidence: 1. During medication observation with staff # 1 which began at 7:25 a.m. on 04/18/2019. Licensing Inspector (LI) observed medications in the medication cart which were already pre-poured to give to residents. 2. LI observed staff # 1 take the pre-poured medications and administer to resident # 1. 3. LI observed two additional resident's medications which were also in a medication cup located in the same place ready for staff # 1 to administer to residents. 4. Staff # 2 directed staff # 1 not to administer the medications that were pre-poured for resident # 2 and # 3. 5. Staff # 1 and # 2 acknowledged that residents # 1, # 2 and # 3 medications had been pre-poured.
Plan of Correction:	The Administrator or designee assures that the Medication Tech will not pre-pour the medication given to the residents. Medication Tech will be sent to refresher course once a year to update his/ her knowledge in proper handling and administration of medication. The medication aide will also be attending more in-service regarding medication. Administrator or designee assures that all medication aides will take time to give medication. Administrator or designee also assures that when administering medication the medication aide will punch out the medication from the medication card, promptly give the medication to the resident, and immediately sign the MAR.
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview the facility failed to ensure that the interior of the buliding is maintained and in good repair. Evidence: 1. Licensing Inspector (LI) conducted tour with staff # 2 and the following was observed: a. In room # 2 there was built up dust on the wall throughout the room. b. In room # 4 built-up dust on the walls and pictures. c. In the women's bathroom under the sink was rusty. 2. Staff # 2 acknowledged the areas during the inspection.
Plan of Correction:	The Administrator and designee will make rounds monthly to inspect the interior and exterior of the building to monitor if any maintenance is required. Room # 2 has been cleaned and dusted by the housekeeping. The handyman already painted the whole room ( interior and exterior), caulk the baseboard, and painted the rusted old AC unit. Housekeeping is done cleaning and dusting with Room # 4. The rust under the sink in the woman's bathroom has been repaired by the plumber. The Administrator and designee will tour the facility to ensure that all bathrooms are clean and in good condition.
Standard #:	22VAC40-73-870-E
Description:	Based on observation and interviews the facility failed to ensure that showers are kept clean and in good repair and condition. Evidence: 1. Licensing Inspector with staff # 2 in the Pink Bathroom observed that the shower curtain had black grim at the bottom of the curtain. 2. In the kitchen the stove had dark stains around the burner. 3. Staff # 2 acknowledged the above during the inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-90-40-B
Description:	Based on record review and interviews the facility failed to obtain criminal history record reports on or prior to the 30th day of employment for each employee. Evidence: 1. Licensing Inspector (LI) with staff # 2 reviewed Staff # 3 ( hired on 03/04//2019) and Staff # 5 ( hired on 12/10/2018) records which did not have criminal background checks. 2. Staff # 2 confirmed there were no criminal backgrounds checks completed for staff # 3 and # 5 by 04/18/2019 the day of the inspection.
Plan of Correction:	Administration or designee assures that potential employees will not be hired until a criminal history record will be submitted by the facility is completed. The Criminal History Record of two (2) new employees have been mailed last April 22, 2019.