VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Emily Green Shores
500 Westmoreland Avenue
Portsmouth, VA 23707
(757) 399-3442

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: May 12, 2022 and May 16, 2022

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

Violations:

Standard #:	22VAC40-73-490-A
Description:	Based on record review and staff interview, the facility failed to ensure that health care oversight was provided at least every six months. Evidence: Staff#1 acknowledged the facility?s last documentation of health care oversight was dated 3/15/21.
Plan of Correction:	Administrator contracted a new Health Care Oversite Nurse. Resident Care Coordinator/Administrator will mark calendar to schedule the Health Care Oversite to ensure it is completed every six months.
Standard #:	22VAC40-73-610-B
Description:	Based on observations made on the posted menu, the facility failed to have any menu substitutions recorded on the posted menu. Evidence: 1. The breakfast menu posted for 5/12/22 was scrambled eggs, biscuits, cold or hot cereal, fruit, juice, and milk. Licensing Inspectors observed the residents eating pancakes as a substitution for biscuits. The substitution was not noted on the menu. 2. The dinner menu posted on 5/16/22 was peppered pork loin, rice, and broccoli. Licensing Inspectors observed the residents eating fried chicken and sweet potatoes as substitutions for peppered pork loin and rice. The substitutions were not noted on the menu.
Plan of Correction:	Dietary Manager will ensure all menu changes will be posted on the menu to match the changes made to the menu board in the dining-room. Dietary Manager responsible for reviewing all menu changes then report changes to the Administrator. Administrator will conduct Radom audits weekly to ensure proper posting of all menu changes.
Standard #:	22VAC40-73-620-A
Description:	Based on documentation review and interview, the facility failed to ensure dietary oversight was conducted every six months for special diets by a dietitian or nutritionist. Evidence: The last oversight review for special diets was dated 8/8/21.
Plan of Correction:	Administrator contracted a new Registered Dietitian Nutritionist to conduct dietary oversite. Resident Care Coordinator/Administrator will date calendar to call a month in advance to ensure dietary oversites are conducted at least every six months.
Standard #:	22VAC40-73-680-I
Description:	Based on documentation review, the facility failed to include all required documentation on the Medication Administration Record (MAR). Evidence: 1. Resident #1 has a physician?s order for Novolog Flex 100u/ml to be administered on a sliding scale. The March 2022 MAR spaces for 3/7, 3/11, 3/19, 3/20, and 3/26 were blank and there was no information documented on the back on the MAR. 2. Resident #1 has a physician?s order to monitor blood sugar four times a day before meals and at bedtime to check blood sugar for diabetes. The March 2022 MAR spaces for 3/7 and 3/12 were blank and there was no information documented on the back on the MAR.
Plan of Correction:	Administrator met with all Medication Aids to consult them on the policy and procedure for drawing blood sugars and administrating sliding scale insulin and recording at time the procedure is done. Resident Care Coordinator will review M.A.R.s weekly to ensure all sliding scale medications are being signed off at time of administration and blood sugar results are recorded as per written physician?s orders. Administrator will audit M.A.R.s throughout month for accuracy.
Standard #:	22VAC40-73-940-A
Description:	Based on a review of the facility documentation the facility failed to ensure that an annual fire inspection was conducted by the appropriate fire official. Evidence: Staff #1 acknowledged the last documented fire inspection for the facility was 4/8/21.
Plan of Correction:	Administrator notified Fire Marshall to remind him that the annual inspection was past due. Maintenance Supervisor/Administrator will continue to mark the calendar to notify Fire Marshall one month in advance then call weekly until he arrives to ensure the Fire Marshall completes annual inspection within the annual timeline.