11143 Warwick Boulevard
Newport news, VA 23601
Current Inspector: Alyshia E Walker (757) 670-0504
Inspection Date: July 26, 2022 and Aug. 4, 2022
Complaint Related: No
- Areas Reviewed:
22VAC40-73 GENERAL PROVISIONS
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
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
63.2 GENERAL PROVISIONS
63.2 FACILITIES AND PROGRAMS
22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES
22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
22VAC40-80 THE LICENSE
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: 07/26/2022, 08/04/2022
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: 25
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 5
Number of staff records reviewed: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Observations by licensing inspector: During the inspection the inspector viewed the buildings and grounds, medication passes, activities and meals.
Additional Comments/Discussion: Facility has already been in contact with the Infection Control Team and the infection control policy has been reviewed.
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 Alyshia E. Walker, Licensing Inspector at (757) 670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Standard #: 22VAC40-73-325-B Description: Based on record review, the facility failed to ensure that a fall risk rating was completed at least annually.
1. Resident #3`s last documented fall risk assessment was dated 6/3/21.
2. Staff #2 acknowledged the last fall risk assessment was completed on 6/3/21.
Plan of Correction: 1. Resident #3?s fall risk assessment was updated on 8/4/22.
2. All resident charts will be audited to ensure fall risk assessments have been
completed within the past 12 months. The resident care coordinator will be
re-educated on completing the fall risk assessments annually.
3. The Director of Nursing/designee will audit resident charts that are due for
annual ISP every month for three months to ensure fall risk assessments have
been done at least annually.
Standard #: 22VAC40-73-720-A Description: Based on record review, the facility failed to ensure the Do Not Resuscitate (DNR) order was documented on the Individualized Service Plan (ISP).
1. Resident #2 has a DNR which was not documented on the resident?s ISP.
2. Staff #2 acknowledged the ISP did not document the resident?s DNR.
Plan of Correction: 1. The ISP for resident #2 was updated to reflect the DNR status.
2. All resident ISPs were audited to ensure accuracy of code status on the ISP. The Resident Care Coordinator will be re-educated on updating the ISP when there is a change in the code status.
3. The Director of Nursing/designee will audit all annual ISPs that are due that month monthly for three months to ensure accuracy of the code status.
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.