VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Discovery Commons Virginia Beach
1628 Old Donation Parkway
Virginia beach, VA 23454
(757) 496-8001

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

Inspection Date: Sept. 27, 2022 and Sept. 28, 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

Technical Assistance:

The current on-site person in charge should to be posted in conspicuous place to the residents and the public.

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/27/2022 from 9:02 am to 3:53 pm and 09/28/2022 from 7:30 am to 10:00 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: 104 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Additional Comments/Discussion: LI observed resident council meeting, reviewed medication carts, and reviewed both the building and vehicle first aid kits. 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 #:	22VAC40-73-610-B
Description:	Based on observation, the facility failed to ensure menu for meals for the current week are dated and posted in an area conspicuous to residents. Evidence: 1. At the time of the inspection on 09/27/2022, the menu for 09/27/2022 was observed to be posted outside in the dining room; however, the menu for meals for the current week were not posted in an area conspicuous to residents.
Plan of Correction:	On 9/27/22 the Director of Culinary Services posted the weekly menu in a conspicuous place. Training will be provided by the Executive Director to the Director of Culinary Services and the Lead Server to assure compliance going forward. This training is to be completed by 10/4/22. The Director of Culinary Services and the Lead Server or designee will assure that the menu is posted appropriately per regulatory standards by this item being placed on the daily checklist for servers. Over the next 90 days, the Executive Director will complete random audits to assure compliance.