VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Mennowood Retirement Community
13030 Warwick Blvd.
Newport news, VA 23602
(757) 249-0355

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: March 18, 2019 and March 20, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-90 The Criminal History Record Report

Comments:

Licensing Inspector for Mennowood Retirement Community, accompanied by a licensing inspector from the Eastern Regional Office conducted an unannounced mandated inspection on March 18, 2018 (9:30 a.m. ? 6:20 p.m.) and March 20, 2018 (2:35pm3:05pm). The purpose of an inspection is to conduct an unannounced review of this facility with a primary focus on the above standards. Licensing inspectors observed lunch, dinner, and the activity for each day. There were 76 residents in care. Observations, review of facility?s records and interviews with residents, staff and family members were conducted during this inspection visit. Licensing inspectors discussed some of the new changes in the standards for licensed assisted living facilities. Licensing inspectors discussed and reviewed all violations cited with the administrator, the director of nursing and the business office manager during the first exit interview. Licensing inspector conducted a second exit interview with the resident care director and the director of dining services on 3/22/2019. Inspection completed by former LI and re-entered due to technical issues.

Violations:

Standard #:	22VAC40-73-450-E
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) contained signatures of the licensee/the plan, and by the resident or his legal representative, and any other individual who contributed to the development of the plan. Evidence: 1. On 3/18/2019, the resident or legal representative did not sign resident #7?s ISP.
Plan of Correction:	New ISP was created 1/22/19, resident passed away 2/2/19. Signature was not obtained before resident passed. Steps to correct the noncompliance with the standard: All ISPs will be signed when they are created. Measure to prevent noncompliance: Administrator or designee will audit ISPs monthly to ensure that they are properly signed.
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 label attached, until administered to the resident. Evidence: 1. On 03/18/19, at 9:50 a.m., during the medication pass observation on the memory care unit with staff #4, Licensing Inspector (LI) observed medication Staff #3 leaving medications inside the cart in a cup unlabeled for resident #9 when she refused medications the first time. 2. During spot check of medication cart, LI observed half of a yellow pillow loose in the bottom, as well as one green pill loose. (around 10:20 a.m.) 3. Staff #3 indicates they are to try three times to get medications to a resident that?s refusing; however, only tried twice with resident #9 before disposing of medications. (see med. management plan)
Plan of Correction:	Steps to correct the noncompliance with the standard: Medication management plan will be followed by all staff. Measure to prevent noncompliance: RMAs and LPNs will be inservices on medication management plan and the importance of proper handling of medication. DON or designee will conduct med pass observations monthly to endure medication management plan is being followed.
Standard #:	22VAC40-90-40-B
Description:	Based on record review and observation of new hired staff in one of twelve, the facility failed to obtain the criminal history record report on or prior to the 30th day of employment for each employee. Evidence: During the inspection conducted on March 18, 2019, Staff #8?s (DOH 7/28/2018) criminal history record report, dated 10/12/2018 was more than 30 days past the acceptable time limit.
Plan of Correction:	Steps to correct the noncompliance with the standard: Criminal history record reports will be obtained on or prior to the 30th day of employment for each employee. Measure to prevent noncompliance: Administrator or designee will audit employee files monthly to ensure criminal history record checks are completed.