VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Elance at Tuckahoe
567 N. Parham Road
Henrico, VA 23229
(804) 554-3939

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Nov. 18, 2021

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 ACCOMODATIONS AND RELATED PROVISIONS 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

Comments:

An initial inspection was initiated on 11/18/2021 and concluded on 12/08/2021. The identified facility Administrator was contacted by email to initiate the inspection. The initial application received at the department noted no residents in care. While onsite on 11/18/2021 and accompanied by the facility Administrator and a facility Director of Nursing the inspector conducted measurements in a total of four different resident living spaces on the first and second floors, conducted a general walk through of the interior of the facility and observed the exterior of the facility upon arrival. An exit interview was conducted with the Administrator and Director of Nursing on 11/18/2021 where technical assistance was offered based on the noncompliance observed and discussions during the inspection. During day two of the inspection on 12/08/2021 the Licensing Administrator for the Peninsula Licensing Office was also present during the onsite inspection. A walk through of the facility was conducted to include measurements taken in two different bedrooms on the third floor of the facility. An exit interview was conducted where findings of 11/18/2021 and 12/08/2021 were 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-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Please contact me at Angela.r.reaves@dss.virginia.gov or (804) 840-0253 if you have any questions

Violations:

Standard #:	22VAC40-73-860-D
Description:	Based on observation and interviews conducted the facility failed to ensure that all doors opened and close readily and effectively any that operable window (i.e., a window that may be opened) is effectively screened. Evidence: During a walk-through of the 3rd floor of the facility on 12/08/2021 the inspector observed that a hall bathroom door when engaged did not readily open and close. During a random observation of resident bedrooms on 11/18/2021 the inspector observed that bedroom #s 130, 134 and 227 did not have screens on the windows. It was revealed during the walk through of the facility on 12/08/2021 that multiple windows in the residents living spaces in the facility?s assisted level of care program and the facility?s safe and secure environment- to include bedroom #s 130, 134 and 227 did not have screens on the windows. In response to the inspector?s inquiry the facility Administrator reported the following via an email on 12/09/2021: 1st Floor: twenty (20) resident bedrooms on the facility?s safe and secure environment are currently without window screens. 2nd Floor: sixteen (16) resident bedrooms and or living rooms are currently without window screens. 3rd Floor: Two resident living rooms and or bed room are currently without window screens. Based on the review of facility documentation and observation the facility did not ensure that operable windows are effectively screened.
Plan of Correction:	FACILITY RESPONSE: "Monitoring: Director of Plant Operations will review handicapped bathroom doors quarterly and make and hinge adjustments if needed. Director of Plant Operations will monitor community windows monthly for damaged or missing screens."
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interviews conducted the facility failed to ensure that the interior of the building is maintained in good repair and free of rubbish. Evidence: As evidenced by the photographs taken on 12/08/2021: Bedroom #118- The top of the window frame on the left side was observed to have a silver colored foil type covering that extended down to the middle of the window frame. By explanation the facility Administrator stated that the window had a leak that was being addressed. There were also window screens and several pieces of wood being stored in a corner of this empty room. Bedroom #130: The bottom of the sliding bathroom door was detached from the door frame. Based on observation the facility did not ensure that interior of the building is maintained in good repair and free of rubbish.
Plan of Correction:	FACILITY RESPONSE: "Director of Plant Operations will periodically assess above HVAC unit and window frame for leaks and items being stored in empty apartments. : The Director of Plant Operations will routinely audit sliding bathroom doors to ensure they are on tracks and in good working condition."
Standard #:	22VAC40-73-870-E
Description:	Based on observation the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, are kept clean and in good repair and condition. As evidenced by the photographs taken on 11/18/2021 the inspector observed the following: Room 134:-a puddle of water observed on the floor coming from under an air conditioner wall unit. Room 130: Bathroom door observed propped against the wall and not attached to the frame of the door. The inspector also observed that a section of the top portion of the bathroom door was detached from the door. As evidenced by the photographs taken on 12/08/2021 the inspector observed that the top portion of the bathroom door was still in ill-repair. As evidenced by the photographs taken on 11/18/2021 and 12/08/2021 the door knobs for the door entering the Four Seasons common area room on the second floor of the facility was still in ill-repair. 12/08/2021: The inspector observed that the doors that lead into the facility?s safe and secure environment were not operable allowing a department representative to exit the safe and secure environment without any restrictions. The vent on the balcony of room #333 was observed to be bent. When engaged by the inspector the wood railing on the second floor across from the Four Seasons common room was observed to be loose from the base.
Plan of Correction:	FACILITY RESPONSE: "Director of Plant Operations will periodically check systems for debris in drain line. Director of Plant Operations will audit doors quarterly for needed repairs due to normal wear and tear. Director of Plant Operations will periodically check the doorknobs to ensure they are in good working order. Director of Plant Operations will routinely audit doors to ensure unit is safe and secure. Director of Plant Operations will periodically audit vents to ensure unit is in good repair. Director of Plant Operations will periodically audit to ensure that handrails are intact and safe."