VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Chesapeake Place
1500 & 1508 Volvo Parkway
Chesapeake, VA 23320
(757) 548-0808

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Oct. 5, 2021 , Oct. 6, 2021 and Oct. 26, 2021

Complaint Related: No

Areas Reviewed:

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 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 63.2 Protection of adults and reporting. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

A renewal inspection was initiated on 10-5-21 and concluded on 10-29-21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 70. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspection reviewed four resident records and four staff records, health and fire inspection, healthcare oversight, nutrition and pharmacy report, fire and emergency drills, activity calendar and staff schedules. The inspector conducted the on-site portion of the inspection on 10-15-21 with an inspector from the Eastern Regional Office. An exit interview was conducted on 10-25-21 and 10-29-21 with the Administrator, Business office manager and Residential Services Coordinator, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1140-B
Description:	Based on record review and staff interview, the facility failed to ensure within four months of the starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairment that meets the requirements of 1140-C of the regulation. Evidence: 1. Staff #6?s record did not document the required 10 hours of cognitive impairment training within 4 months of start of employment. Staff?s date of hire documented as 9-8-20; staff?s record documented 6 hours of training on 9-8-20. 2. Staff #7?s record documented 6 hours of cognitive impairment training on 5-6-21; staff?s date of hire documented as 5-6-21. 3. During exit on 10-25-21 and 10-29-21, staff #1 acknowledged staff #6 and #7 did not have the required hours of cognitive training.
Plan of Correction:	Staff #6 and #7 will complete the required 12/31/2021 10 hours of cognitive training. Business Office Manager and or designee will create a training tickler for all direct care staff employed and ensure that the required cognitive training is completed in the first four months of employ. Business Office Manager and or designee will notify the Executive Director and or designee of any staff that have not completed the cognitive training in the required four months, so that they can be removed from the schedule until time of completion.
Standard #:	22VAC40-73-40-A
Description:	Based on record review, document review and staff interview, the facility failed to ensure it was in compliance with its own policies and procedures. Evidence: 1. Resident #2's uniform assessment instrument (UAI) dated 9-17-21 documented medication administered by registered medication aide and licensed practical nurse. The resident's individualized service plan (ISP) dated 9-17-21 documented resident is able to self- administer supplement and keep at bedside. Resident is currently assessed and assigned to the facility's safe, secure unit. 2. The facility medication administration policy document, Resident Self-Management/ Storage of Medication, "Residents with a diagnosis of memory impairment will not be permitted to self-manage their medication. 3.On 10-29-21, facility policy reviewed with staff #1.
Plan of Correction:	RSC or designee will correct resident #2's ISP for compliance in medication administration. RCC or designee will audit resident ISPs for compliance in medication administration with cognitive impairment. Business Office Manager or designee will document training with medication administration and cognitive impairment with all staff schedule in medication administration.
Standard #:	22VAC40-73-210-B
Description:	Based on record review and staff interview, 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. For direct care staff who are licensed health care professionals or certified nurse aides shall attend at least 12 hours of annual training. Evidence: 1. Staff #4?s record did not contain documentation of the required 18 hours annual training. Staff?s date of hire documented as 6-18-19. 2. Staff #6?s record documented 10.25 hours of the required 12 hours of annual training. 3. During exit on 10-25-21 and 10-29-21 staff #1 acknowledged staff #4 and #6 did not have documentation of the required hours of annual training.
Plan of Correction:	Business Office Manager and or designee 1/15/22 will schedule, conduct and document the complete 12-18 hours of state required training for staff #4 and #6. Business Office Manager or designee will create a tickler for all care staff to monitor, record and ensure compliance in the required state training for each staff member. Business Office Manager or designee will inform Executive Director and or designee of any non-compliance of state required trainings so that the staff member can be removed from the schedule until training compliance is completed.
Standard #:	22VAC40-73-210-F
Description:	Based on record review and staff interview, the facility failed to ensure at least two of the required hours of training shall focus on infection control and prevention. When adults with mental impairment reside in the facility, at least four of the required hours shall focus on topics related to residents? mental impairment. Evidence: 1. Staff #4 record did not contain documentation of mental health and infection control and prevention training. 2. Staff #6?s record documented 1.0 of the required 2.0 hours of infection control and prevention training. 3. During exit on 10-25-21 documents were requested. However, there were not additional training records provided for staff #4 and #6?s. 4. During exit on 10-29-21, staff #1 acknowledged staff #4 and #6 did not have documentation of the required mental health and infection control and prevention training.
Plan of Correction:	RCC and or designee will schedule additional training in infection control and mental impairment for staff #4 and #6 to meet training compliance. RCC and or designee will review infection control training and mental impairment topics are covered in the community training materials to meet state compliance going forward.
Standard #:	22VAC40-73-250-C
Description:	Based on record review and staff interview, the facility failed to ensure staff record included documentation of a sworn disclosure statement for two of the four sampled records. Evidence: 1. Staff #6?s record did not contain documentation of a sworn disclosure statement, staff?s date of hire 9-8-20. 2. During exit on 10-25-21 documents were requested and received on 10-26-21 and 10-27-21, however, staff #6?s sworn disclosure was not received. 3. During exit on 10-29-21, staff #1 acknowledged staff #6?s sworn disclosure was not provided during renewal review.
Plan of Correction:	Business Office Manager or designee will obtain sworn disclosure from staff member #6. Business Office Manager or designee will include the sworn disclosure in the employee cover checklist in each employee file for compliance. Date of completion 7 days. Business Office Manager or designee will inform Executive Director or designee if a sworn disclosure is not obtained for each new hire so that it may be obtained prior Ito first day of employment. Date of completion is immediate and ongoing.
Standard #:	22VAC40-73-250-D
Description:	Based on record review and staff interview, the facility failed to ensure the initial tuberculosis (TB) examination and report for a staff person was completed on or within seven days prior to the first day of work at the facility. Evidence: 1. Staff #7?s initial documentation of tuberculosis (TB) was documented 5-29-21. Staff?s date of hire documented as 5-6-21. 2. During exit on 10-29-21, staff #1 acknowledged staff #7?s TB date was after the required time. 250-D.2 Based on record review and staff interview, the facility failed to ensure a staff person was evaluated annually and submitted the results of a risk assessment, documenting that staff was free of tuberculosis (TB) in a communicable form as evidenced by the completion of a current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 3. Staff #4?s record did not contain documentation of an annual risk assessment. Staff?s record documented a chest X-ray conducted on 2-12-20; date of hire documented as 6-18-19. 4. Staff #6?s record did not contain documentation on an annual risk assessment. Staff?s dated of hire documented as 9-8-20. 5. During exit on 10-25-21 documents were requested. However, staff #4 and #6?s TB were not included with documents provided on 10-26-21 and 10-27-21. 6. During exit on 10-29-21, staff #1 acknowledged staff #4 and #5?s TB were not provided during renewal review.
Plan of Correction:	RSC or designee will obtain staff #4 and #6 annual TB risk assessment.. Business Office Manager and or designee will ensure TB results are obtained prior to the first day worked for new hires. Business Office Manager will notify Executive Director and or designee immediately of any results not received prior to first scheduled work day to ensure compliance. Business Office Manager or designee will create a tickler to include new hire TB compliance and current staff TB compliance dates. Business Office Manager or designee will inform Executive Director and or designee bf any staff member not in compliance so that they may be removed from the schedule until TB requirements are met.
Standard #:	22VAC40-73-280-A
Description:	Based on document review and staff interview, the facility failed to ensure it had staff adequate in knowledge, skills, and abilities sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with the regulation. Evidence: 1. The nursing schedule for medication aide and direct care staff for October 3 through October 16, 2021 did not include a medication aide for the following dates and shift: (a) 10-3-21, 11p- 7a; (b) 10-8-21, 11p?7a; and (c) 10-11-21, 11p?7a. 2. The nursing schedule also documented one staff in the Assisted Living Building on the aforementioned dates and shift time. The facility census for the assisted living was documented as 58 on 10-31-21, and 57 on 10?8 and 10-11-21. The assisted living unit have residents on the unit who are two-person assist and non-ambulatory on those dates mentioned. 3. During the exit on 10-25-21, staff #1 acknowledged the scheduled did not document a medication staff on the aforementioned shifts.
Plan of Correction:	Resident Services Coordinator and or designee shall create and publish the appropriate staffing schedule to meet current resident needs. Executive Director and or designee is to be notified immediately if needed levels of staffing are insufficient either in numbers or position. This allows the Facility to make contingent arrangements for staffing levels to meet the needs of the residents.
Standard #:	22VAC40-73-290-A
Description:	Based on record review and staff interview, the facility failed to ensure the facility written work schedule include the names and job classification of all staff working each shift, with an indication of whomever is in charge at any given time. Evidence: 1. The facility?s written nursing department schedule for direct care staff and medication aides and the dietary department schedule documented only the first name of staff scheduled. 2. The nursing department schedule documented ?Med-Aides are in Charge of Shift?. However, there were shifts that document more than one medication aide, with no specific aide documented as the staff person in charge. 3. On 10-15-21, during the on-site visit, two medication aides were present, but neither staff knew who was in charge. 4. During exit on 10-25-21, staff #1 acknowledged the scheduled did not specify who was in charge.
Plan of Correction:	RSC or designee will create a schedule reflecting the first and last name of each staff member, the day, time and which scheduled position is the staff person in charge.
Standard #:	22VAC40-73-290-B
Description:	Based on observation and staff interview, the facility failed to ensure the posting of the name of the current on-site person in charge, as required per the regulation, was in place in the facility that is conspicuous to the residents and the public. Evidence: 1. During a tour of the facility on 10-15-21, the staff person in charge was not posted. According to the information posted at 7:50 a.m. the administrator, who was not on-site was posted as the staff person in charge. 2. Staff #1 acknowledged the staff person in charge was not accurately posted.
Plan of Correction:	Concierge and or designee will post the staff person in charge on the entrance desk so that it is visible to everyone.
Standard #:	22VAC40-73-310-H
Description:	Based on record review and staff interview, the facility failed to ensure it did not admit and or retain individuals with any prohibitive conditions or care needs per the regulations. Evidence: 1. During the remote inspection, resident #1?s September medication administration record (MAR) submitted documented the following psychotropic medications, Paxil, Haloperidol and Lorazepam without a treatment plan. 2. Resident #2?s September 2021 MAR documented the following psychotropic medications, Citalopram, Clonazepam and Sertraline without a treatment plan. A request for treatment plan was made on 10-25-21 during the exit meeting. Treatment plans dated 10-27-21 were received for the aforementioned psychotropic medications for resident #2. 3. Resident #4?s September 2021 MAR documented Trazadone psychotropic medication without a treatment plan. 4. During the exit on 10-25-21, staff $1 acknowledged the facility did not have treatment plans for psychotropic medication prior to and during admission. Resident #2?s treatment plans were obtained by the facility following the exit interview on 10-25-21.
Plan of Correction:	RSC or designee will obtain treatment plan for Resident #1 . Date of completion 14 days. RSC or designee will review current residents for compliance with treatment plans and update as needed. RSC or designee will obtain completed treatment plans for any new admissions with psychotropic medications at the time of physical move in Immediately and ongoing.
Standard #:	22VAC40-73-320-B
Description:	Based on record review and staff interview, the facility failed to ensure a risk assessment shall be completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. Resident #4?s record did not contain documentation of an annual risk assessment. Resident?s record document date of admission as 4-16-19. 2. During exit on 10-25-21 documents were requested. However, resident #4?s TB was not included with documents provided on 10-26-21 and 10-27-21. 3. During exit on 10-29-21, staff #1 acknowledged resident #4?s TB not provided during renewal review.
Plan of Correction:	RSC or designee will obtain an annual TB 12/5/2021 risk assessment for resident #4. RSC or designee will create a tickler for resident annual TB risk assessments and monitor for compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure uniformed assessment (UAI) for private pay individuals in the assisted living facility is completed as required. Evidence: 1. Resident #1?s uniformed assessment instrument (UAI) dated 10-4-21 documented resident need for eating/feeding assessed as human help/physical assistance (hh/pa). The individual service plan (ISP) dated 10-4-21 documented need as human help/supervision (hh/s); resident ?will receive verbal cues and reminders to attend meals and to continue to feed self for the duration of the meal?. Interview with staff #1 on 10-25-21, staff stated resident did not require physical assistance. 2. Resident #2?s UAI dated 9-17-21 documented medication is administered by registered medication aide (RMA) and licensed practical nurse (LPN). The individual service plan dated 9-17-21 documented resident ?receives supplement nutritional drink as physician order. Resident able to self-manage. Resident has an order to keep at bedside?. Interview with staff #1 on 10-25-21, staff stated resident?s medication kept at bedside. 3. Resident #3?s uniformed assessment and individualized service plan documents were requested on 10-6-21 as one of four sample records for review but documents were not received. On 10-25-21 during the exit with staff #1, records were requested. However, documents were not received for review during the renewal. 4. Resident #4?s UAI dated 7-6-21 documented resident did not need assistance with money management. Resident?s ISP dated 7-6-21 documented, ?POA will assist with financial management as needed?. 5. During exit on 10-25-21 and 10-29-21, staff #1 acknowledged residents? UAIs and ISPs did accurately reflect assessed needs and or care plan documented. Also, resident #3?s UAI and ISP were not provided for review.
Plan of Correction:	RSC or designee corrected Resident's #1, #2, #3 and #4's assessments. RSC or designee will audit of current resident ISP/UAl's for compliance. RCC or designee created a tickler for UAI/ISP compliance and monitoring which will be maintained daily. Executive Director and or designee will review tickler monthly for compliance.
Standard #:	22VAC40-73-450-E
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the license, or this designee, and by the resident or his legal representative. Evidence: 1. Resident #2's individualized service plan (ISP) dated 9-17-21 was not signed by the resident or his legal representative. 2. Staff #1 acknowledged on 10-29-21 resident's ISP was not signed by the resident nor the legal representative.
Plan of Correction:	RCC or designee will obtain signatures on 1/15/2022 Resident #2's ISP for compliance. RCC or designee will audit ISPs for signature compliance.
Standard #:	22VAC40-73-450-F
Description:	Based on record review and staff interview, the facility failed to ensure a resident?s individualized service plan was updated as needed as the condition of the resident changed. Evidence: 1. Resident #2?s individualized service plan (ISP) dated 91-17-21 was not updated to include the resident?s speech therapy services. Resident?s therapy notes documented Speech Therapy services was initiated on 9-9-21 and recertified on 10-10-21. 2. Resident #1?s therapy notes documented occupational therapy initiated on 9-10-21 and discharged on 10-5-21. 3. Resident #2 ISP was not updated to include the resident?s occupational and speech therapy services. 4. During exit on 10-25-21, staff #1 acknowledged the aforementioned therapy services for resident #1 was not documented on the resident?s ISP.
Plan of Correction:	RCC and or designee will correct Resident #1 and #2's ISP for compliance. RCC or designee will audit of resident ISP's or compliance and correct. Executive Director and or designee will review all lSPs at the time of signature. Date of completion immediate and ongoing.
Standard #:	22VAC40-73-550-G
Description:	Based on record review and staff interview, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative and each staff person. Evidence: 1. Staff #4?s record did not contain documentation of annual rights review, date of last review in record was documented 6-18-19. 2. Staff #6?s record documented resident rights last review was dated 9-8-20. 3. During exit on 10-25-21 documents were requested. However, staff #4 and #6?s resident?s rights were not included with documents provided on 10-26-21 and 10-27-21. 4. During exit on 10-29-21, staff #1 acknowledged staff #4 and #5?s resident?s rights were not provided during renewal review.
Plan of Correction:	Business Office Manager or designee will review resident rights and responsibilities of residents in assisted living facilities with staff member #4 and #5 and document. Business Office Manager and or designee twill create a tickler for staff and a tickler for residents to monitor the rights and responsibility of residents in assisted living facilities is reviewed within the compliancetimeframes. Business Office Manager or designee will inform Executive Director and or designee of any staff or residents that are not in compliance so that it may be corrected. Executive Director and or designee will reach out to ombudsman to schedule a rights and responsibility of residents in assisted living facilities training. Date of completion 7 days to make request and 90 days to schedule training.
Standard #:	22VAC40-73-640-A
Description:	Based on record review and staff interview, the facility failed to ensure the medication management plan was followed. 640-A .4 (missed dosage) 1. Resident #1?a Tramadol medication which is administered three times a day, was not available to administer two times on 10-19-21 and three times on 9-20-21. Staff #1, stated facility was waiting for Hospice representative to re-order medication. Resident #1?s September 2021 medication administration record (MAR) documented the original date of medication was dated 4-21-21. Resident?s Amitiza, administered twice a day, not available three times 9:00 a.m. and three times 5:00 p.m. Resident?s September MAR documented the original date of 8-18-21 and discontinued 9-6-21. 640-A.5 (24 hour documentation) 2. Resident #2?s September 2021 medication administration record (MAR) did not document physician?s order dated 8-30-21 for Boost shakes. 3. Resident #3?s September 2021 MAR did not document physician?s order dated 9-2-21 for Nutritional Shake supplement. Resident #4s September 2021 MAR did not document physician?s order dated 5-4-21 for Tramadol PRN. 4. The facility?s ?Med 01- Community Medication Management Plan, policy date 12-01-2020? -document medication would be transcribed on MARS within 24 hours of receipt of a new order or change in an order. The plan also documented plan shall address methods for filling and refilling prescriptions to avoid missed dosages. 5. During exit on 10-25-21, staff #1 acknowledged the MAR did not include medications for the physician?s orders.
Plan of Correction:	RSC and or designee will correct Resident #1, #2 and #3's MAR for compliance. RSC or designee will request pharmacy to conduct a documented training for the filling and refilling of medications for all staff assigned to medication administration to prevent missed doses and ensure timely refills. Date of Completion 60 days. Business Office Manager and or designee will document training of all staff that are assigned to medication administration to review Medication Management Plan for compliance.
Standard #:	22VAC40-73-680-I
Description:	Based on record review and staff interview, the facility failed to ensure the medication administration record (MAR) included all of the required information. Evidence: 1. Resident #1?s September 2021 medication administration record (MAR) did not include initials of direct care staff administering A & D ointment six times. 2. Resident #4?s September 2021 MAR did not include a diagnosis. Condition, or specific indications for administering the drug Prilosec. 3. During exit on 10-25-21, staff #1 acknowledged the MAR did not include all required information.
Plan of Correction:	Resident #1 and #4 were corrected on 10/31/2021. RSC and or designee will review all MARs on a monthly basis for compliance and thoroughness of information.
Standard #:	22VAC40-73-870-A
Description:	Based on observation and staff interview, the facility failed to ensure the building was maintained in good repair and kept clean. Evidence: 1. On 10-17-21 at 07:30 a.m. during a tour of the facility, the front porch was observed with building materiel left uncovered. Ladders of various sizes, a pallet of concrete mixtures, downspouts, caulking guns, moving dollies, piles of lumbers, paint scrapers, nails of various sizes in multiple containers, the base of a lamp, concrete hand tool, assorted ropes, old patio chairs and chair cushions, a shop vac equipment and metal rods along with other types of debris and equipment on the front porch/ entrance to the facility. The porch was not fully sectioned or roped off to keep the residents and others from entering the area being used as work area. The hallway to the left of room #35 and the activity room ceiling lights were dangling by the wire. 2. Residents and others were observed entering and exiting the facility from the front porch entrance where the clutter and debris were observed by licensing. 3. Staff #1 acknowledged the individuals who were completing the renovation in the assisted living unit did not leave the facility in a safe manner the previous evening.
Plan of Correction:	The storage of construction materials will 11/1/2021 be maintained and kept with physical barriers to prevent residents from entering. Any fixtures removed during repairs will be replaced properly when the work is completed or in a safe manner until repairs are complete. Maintenance Director and or designee will monitor all repairs during building walkthroughs for compliance to ensure resident safety
Standard #:	22VAC40-73-930-A
Description:	Based on observation and staff interview, the facility failed to ensure the signaling device was audible in a manner that permit staff to determine the origin of the signal. Evidence: 1. During the tour of the facility on 10-15-21, the signaling cord was press by the resident in room #35 at 8:20 a.m. without a staff response. The signaling cord in the resident?s bathroom was pulled at 8:29 a.m. without a staff response. The administrator came to the hallway near room #35 at approximately 08:45 a.m. and was informed of the signaling device situation. The administrator was informed by staff that the pager was being charged, therefore staff did not know the signaling device was activated. 2. Resident in room #35 is non-ambulatory and requires staff assistance to transfer from wheelchair. 3. Staff #1, acknowledged on 10-15-21 that the signaling device was not audible to staff assigned to the hallway where room #35 was located.
Plan of Correction:	RSC or designee is to assign a pager to each shift supervisor to monitor for response. RSC or designee will conduct a documented training with all care staff on proper pager use and charging.
Standard #:	22VAC40-73-970-A
Description:	Based on document review and staff interview, the facility failed to ensure fire and emergency drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month. Evidence: 1. The facility fire and emergency drill document for July, August and September 2021 did not include fire drills for the 11p---7a shift. 2. During the exit on 10-25-21, staff #1 acknowledged the drills were not conducted for all three shifts, particularly the 11p?7a shift.
Plan of Correction:	Maintenance Director and or designee will create an annual fire drill calendar to include a rotation of a different shift each month in succession to be implemented, documented and monitored. The completed calendar will be shared with the Executive Director and or designee for compliance and monitoring.
Standard #:	22VAC40-90-40-B
Description:	Based on documents reviewed and staff interview, the facility failed to ensure the criminal history record report shall be obtained on or prior to the 30th day employment for each employee. Evidence: 1. On 10-6-21, the facility did not have documentation of the criminal history record report for fourteen new hires on or prior to the 30 th day of employment. The new hires dates ranged from May 6, 2021 to September 21, 2021 2. During the exit on 10-25-21, staff #1 acknowledged the facility did not obtain on or prior to the 30th day of employment a criminal history record for new employees since the date of hire.
Plan of Correction:	Facility retained a new account with the Virginia State Police on 9/15/2021. Business Office Manager and or designee will audit current employee files to include the 14 employees listed and a review of the current staff records for compliance. A tickler will be created by Business Office Manager or designee to include all new hires and track compliance of requesting a state background check and other required documentation and obtain within 30 days.