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

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: June 9, 2022 and June 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
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES
22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:
Type of inspection: Renewal
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/09/2022 from 9:23am to 3:10pm and 06/16/2022 from 8:25am to 9:47am.
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.

Number of residents present at the facility at the beginning of the inspection: 72
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 9
Number of staff records reviewed: 5

An exit meeting will be conducted to review the inspection findings.

The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.

If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview.

Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.

Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.

Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.

The department's inspection findings are subject to public disclosure.

Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.

For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov

Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:
Standard #: 22VAC40-73-1090-A
Description: Based on record review and interview, the facility failed to ensure prior to admission to a safe, secure environment, residents have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.

Evidence:

1. Resident #4 admitted to the safe, secure environment on 4/15/2021; however, the Physician Assessment of Serious Cognitive Impairment for Admission to Memory Care Center completed was not dated.

2. Staff #6 acknowledged the assessment for Resident #4 was not dated to ensure it was completed prior to admission.

Plan of Correction: Physician dated form with the date that he assessed the resident for the Memory Care floor.

Admissions/Marketing will audit all memory care files.

Admissions/Marketing to ensure Cognitive Impairment form is signed and dated prior to admission will have DON to review completed assessment for accuracy prior to admitting resident to the secured unit.

Admissions/Marketing Director or designee to audit Memory Care resident admission files monthly for two months and then ongoing as need to ensure accuracy and compliance.

Standard #: 22VAC40-73-250-C
Description: Based on record review and discussion, the facility failed to maintain personal and social data on staff to include verification that the staff person has received a copy of his current job description.

Evidence:

1. Staff #4 started a new role effective 05/02/2022; however, the record for Staff #4 did not include verification that the staff person has received a copy of his current job description.

2. Staff #6 acknowledged the record did not include the missing item.

Plan of Correction: Job description was immediately signed and placed in file.

Business Office Manager will audit all employee files to ensure signed for job descriptions are in place.

Business Office Manager or designee will complete log on each new hire to ensure compliance.

Business Office Manager or designee will continue to do monthly audits of all new hire files for two months and then ongoing as needed.

Standard #: 22VAC40-73-260-A
Description: Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.

Evidence:

1. Staff #5 works as direct care staff and does not have a current certification in first aid.

Plan of Correction: Employee to complete First Aid training by August 30, 2022

Business Office Manager to monitor and log each new hire for completion of First Aid Training.

Business Office Manager to ensure staff upon hire attend First Aid Training within first 60 days of employment.

Business Office Manager/designee will conduct a monthly audit of employees files for current First Aid certificate for two months then ongoing as need to ensure compliance.

Standard #: 22VAC40-90-40-B
Description: Based on record review and discussion, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee.

Evidence:

1. Staff #7, Staff #9, and Staff #10 do not have a completed criminal history record reports through the Virginia State Police.

2. Staff #6 acknowledged the facility did not obtain a criminal history record reports within the required timeframe through the Virginia State Police.

Plan of Correction: Staff #7, Staff #9 and Staff #10 criminal checks were redone.

Business office manager or designee will do an audit of all employee files for compliance of criminal checks for employees.

Business Office Manager or designee to monitor and log each new hire for completion of background check.

Business Office Manager or designee will ensure completion of background checks are done on all new hires within 30 days of hire. BOM or designee will audit new files monthly for two months then ongoing as needed.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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