VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harbor's Edge
One Colley Avenue
Norfolk, VA 23510
(757) 233-0475

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: July 25, 2022 and July 26, 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: 07/25/2022 from 8:27 am to 4:30 pm and 07/26/2022 from 8:25 am to 10:20 am. 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: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Observations by licensing inspector: medication pass, breakfast and lunch meal service and required postings. 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 #:	22VAC40-73-1100-A
Description:	Based on record review, the facility failed to obtain the written approval of one of the following persons listed in the standard of placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment. Evidence: 1. Resident #1 admitted to the special care unit on 03/02/2022; however, Resident #1 did not have documentation of approval for placement in a special care unit in the resident record.
Plan of Correction:	The approval for placement in a special care unit form has been signed with a summary of acknowledgement that the approval was received at the time of placement. It is now included in the resident record. An audit of required forms was conducted for all residents in the special care unit to ensure compliance. The Assisted Living manager/designee will ensure that all residents in need of special care unit placement has the appropriate paperwork completed and included in the resident record.
Standard #:	22VAC40-73-210-A
Description:	Based on record review, the facility failed to ensure all direct care staff shall attend at least 18 hours of training annually with the exception of direct care staff who are licensed health care professionals or certified nurse aides attend at least 12 hours of annual training. Evidence: 1. Staff #4 (hire date 2/13/2007) works as a RMA/CNA and does not have any documentation for training completed over the past year.
Plan of Correction:	Staff #4 will receive the required training and documented completion. An audit will be conducted of all staff training to ensure completion and documentation in place. The Assisted Living manager/designee will conduct monthly audits of training to ensure compliance and report any findings and/or trends to the Quality Assurance committee.
Standard #:	22VAC40-73-250-C
Description:	Based on record review, 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. The record for Staff #1 and Staff #2 did not include verification that the staff person has received a copy of their current job descriptions.
Plan of Correction:	Staff #1 and #2 employment records have been updated to include verification that a current job description has been provided to those staff members. The Human Resource manager/ designee will ensure that all employees are provided with and acknowledge receipt of their job description. The Human Resource manager/ designee will audit all new employee files for the next eight weeks to ensure that verification of a current job description is included in their employee record and report any findings and/or trends to the Quality Assurance committee.
Standard #:	22VAC40-73-325-B
Description:	Based on record review, the facility failed to ensure a fall risk rating is completed after a fall. Evidence: 1. Upon review of the resident?s record, Resident #5 has falls documented in progress notes on 02/05/22, 03/01/2022, and 04/17/2022; however, there is no documentation of a fall risk rating being completed after each fall in the resident?s record. 2. Upon review of the resident?s record, Resident #6 had a fall documented in progress notes on 03/14/2022; however, there is no documentation of a fall risk rating being completed after the fall in the resident?s record.
Plan of Correction:	A fall risk rating assessment has been completed on resident #5 and #6. The Assisted Living manager/designee conducted audits to ensure that fall risk rating assessments have been completed on all current residents who have experienced a fall to date. The Assisted Living manager/ designee will in-service those responsible for completing the assessments to include frequency and required documentation. Audits will be conducted for the next eight weeks to ensure timely completion and report any findings and/or trends to the Quality Assurance committee.
Standard #:	22VAC40-73-330-A
Description:	Based on record review, the facility failed to ensure a mental health screening be conducted prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual. Evidence: 1. Resident #1 (admitted 02/28/2022) did not have a copy of a mental health screen in their record.
Plan of Correction:	A mental health screening has been completed and included in the record for Resident # 1. The Assisted Living manager conducted an audit of all current residents to ensure a completed mental health screening was performed and included in the resident record. The Assisted Living manger/ designee will conduct audits for the next eight weeks of all new admissions to ensure completion, inclusion in the resident record and report any findings and/or trends to the Quality Assurance committee.
Standard #:	22VAC40-73-350-B
Description:	Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the date the information was obtained. Evidence: 1. Resident #2 admitted into assisted living on 03/29/2022; however, the sex offender screening was completed on 7/25/2022. 2. Resident #4 admitted into the facility on 08/05/2021; however, the sex offender screening was completed on 08/30/2021.
Plan of Correction:	All current residents have sex offender screenings completed and documented. The Admissions Coordinator has been in-serviced regarding sex offender checks being performed and documented prior to admission. The Assisted Living manger/ designee will conduct audits for the next eight weeks for all new admissions to ensure compliance and report any findings and/or trends to the Quality Assurance committee.
Standard #:	22VAC40-73-440-A
Description:	Based on record review and interview, the facility failed to complete resident?s UAI at least annually. Evidence: 1. Two of the seven resident records reviewed did not have an updated UAI: Resident #5?s last UAI completed 03/17/2021 and Resident #7?s last UAI completed on 01/04/2021. 2. Staff #8 acknowledged the UAIs for Resident #5 and Resident #7 were not completed at least annually.
Plan of Correction:	Updated UAIs for residents #5 and #7 were completed on 7/25/2022. All current resident records were reviewed to identify any UAI?s not updated timely. The Assisted Living manager/designee conducted in-services for staff responsible for UAI completion. Audits will be conducted for the next eight weeks to ensure compliance and report any findings and/ or trends to the Quality Assurance committee.
Standard #:	22VAC40-73-440-B
Description:	Based on record review, the facility failed to ensure that the uniform assessment instrument is completed as required by 22VAC30-110 for private pay individuals. Evidence: 1. The UAIs for Resident #2 (dated 03/25/2022 and 03/30/2022), Resident #3 (dated 12/23/2021), Resident #4 (dated 12/24/2021), and Resident #6 (dated 01/07/2022) were not signed for approval by the administrator or designee.
Plan of Correction:	All UAIs have been updated with appropriate signatures. All parties responsible for review and approval of UAIs were in-serviced on completion and approval in a timely manner. The Assisted Living manager/ designee will conduct audits for the next eight weeks to ensure compliance and report any findings and/or trends to the Quality Assurance committee.
Standard #:	22VAC40-73-550-G
Description:	Based on record review, the facility failed to annually review the rights and responsibilities of residents with each staff person. Evidence: 1. The records of Staff #1, Staff #2, and Staff #4 do not include written acknowledgement of having been so informed of the review of the rights and responsibilities of residents.
Plan of Correction:	An in-service was conducted with Staff #1, #2 and #4 to review and acknowledge resident rights and responsibilities of residents. All staff records will be audited to identify records not in compliance. The Human Resource Director/designee will ensure annual training reviewing and acknowledging resident rights and responsibilities of residents is complete and report any findings and/or trends to the Quality Assurance committee.
Standard #:	22VAC40-73-940-A
Description:	Based on record review, the facility failed to comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: 1. The last inspection by the appropriate fire official was completed on 11/20/2019.
Plan of Correction:	The Norfolk Fire Department was contacted previously to schedule and annual fire inspection. The Life Safety Coordinator will contact the local fire department annually to schedule an inspection to ensure compliance with the standard.