VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Elance at Tuckahoe
567 N. Parham Road
Henrico, VA 23229
(804) 554-3939

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Nov. 14, 2022 and Dec. 15, 2022

Complaint Related: No

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: 11/14/2022-12:27p.m-4:22p.m 12/15/2022-1:21p.m-5:36p.m 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: 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: 5 Number of interviews conducted with residents: Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1180-B
Description:	Based on observation and interview conducted the facility failed to ensure that when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects must not be inaccessible to the resident except under staff supervision. Evidence: 11/14/2022: During a walkthrough of the safe and secure environment accompanied by facility staff #6 and as evidenced by the photographs taken, unsupervised and easily accessible hazardous items were left on tables on the unit. The noncompliance and photographs taken were reviewed with the Administrator.
Plan of Correction:	FACILITY RESPONSE: "For the next five weeks, through February 17, 2023, Director of Virtue Memory Care (DOV), Manager on Duty or supervisor in charge will conduct and document daily safety rounds in Virtue Memory Care to ensure potentially harmful materials are secured."
Standard #:	22VAC40-73-40-B-6
Description:	Based on the review of facility records and interviews conducted with the facility Administrator and other facility staff, the licensee failed to exercise general supervision over the affairs of the licensed facility and establish policies and procedures concerning its operation in conformance with applicable law, this chapter, and the welfare of the residents. Evidence: The facility?s Intensive Plan of Correction (IPOC) received at the department on 10/27/2022 notes that during weekly phone calls between the Regional Director of Operations (RDO) and the facility Administrator -observed or reported concerns and resolutions will be discussed. Upon request on 12/30/2022 to review documentation that identified the RDO?s and Administrator?s oversight of the IPOC the facility Administrator submitted an E.D. and R.D.O. weekly calls document- charting for October, November and December 2022. The E.D and R.D.O document also notes ?Document any outstanding concerns and pending resolutions below with a projected timeline of a final resolution. The document, however, does not identify that the RDO or facility Administrator is aware of the 10/14/2022 Weight Audit notations or that residents refuse weights, facility staff are documenting incorrect weights, or that resident weights were redone in November and December 2022 to ensure the accuracy of previously recorded weights for October, November and December 2022. The facility?s? offer that the IPOC submitted ?provides steps (tools and methods) that will be taken to prevent violation(s) in the referenced area(s) from occurring in the future? is not being implemented. The facility?s offer that because of the Administrator?s credentials oversight is not indicated is not supported as repeat and new violations is contained within this report.
Plan of Correction:	FACILITY RESPONSE: "For the next five weeks, through February 17, 2023, applicable audits, training, and other resources utilized to verify substantial compliance as referenced throughout this plan of correction will be verified by facility E.D., a second Virginia Licensed Assisted Living Administrator and appropriate licensee designated support individuals."
Standard #:	22VAC40-73-120-A
Description:	Based on the review of facility records and interviews conducted the facility Administrator and Business Office Director the facility failed to ensure that orientation and training required in subsections B and C of this section occurred within the first seven working days of employment. Evidence: For example, Facility staff: #1- Documented date of hire 11/08/2022 #2- Documented date of hire 11/08/2022 #3- Documented date of hire 11/08/2022 Upon request the facility did not submit for the inspectors? review documentation that orientation was provided to staff #s 1, 2 and 3 as required.
Plan of Correction:	FACILITY RESPONSE: "DSS model form-record of initial staff training for all new hires will be reviewed and initialed by the E.D., within 24 business hours of training completion), through February 17, 2023. Ongoing inspections by licensee designated support staff will complete additional audits."
Standard #:	22VAC40-73-150-C
Description:	Based on the review of facility records and interviews conducted with the facility Administrator, the Business Office Director and other facility staff, the Administrator failed to be responsible for the general administration and management of the facility and failed to oversee the day-to-day operation of the facility. This shall include responsibility for: Evidence: ? Facility staff are not being provided supervision when developing resident Individualized Service Plans as identified needs, written description of what services will be provided to address identified needs of residents are not being consistently identified. ? A residents? ISP is documented to note that staff will provide assistance with activities of daily living even though the facility has assessed the resident as being totally dependent on others to perform these tasks. ? Resident ISPs are not being developed based on assessed needs of the residents and the language in the ISPs for residents were revealed to be duplicates of the other and not individualized based on the assessed and or reported needs of the residents. ? Documentation of new employee orientation, verification of staff credentials not being maintained. ? The Business Office Director is signing documentation that she conducted new staff orientation. However, during interviews she stated that she is not knowledgeable about current Standards for Licensed Assisted Living Facilities. ? Unsupervised hazardous material was observed on the safe and secure unit. ? The facility Administrator signed an incomplete 11/16/2022 Uniform Assessment Instrument (UAI) for a resident. The Administrator is not providing oversight to facility staff ensuring that the Intensive Plan of Correction (IPOC) is being implemented.
Plan of Correction:	FACILITY RESPONSE: "For the next five weeks, through February 17, 2023, applicable audits, training and other resources utilized to verify substantial compliance as referenced throughout this plan of correction will be verified by facility E.D., a second Virginia Licensed Assisted Living Administrator and appropriate licensee designated support individuals."
Standard #:	22VAC40-73-250-C
Description:	Based on the review facility records and interviews conducted with the Business Office Manager and the facility Administrator, the facility failed to ensure that a system was in place to verify the current professional license, certification, registration, medication aide provisional authorization, or completion of a required approved training course. Evidence: Staff #1 Documented date of hire 11/08/2022 #2- Documented date of hire 11/08/2022 #3-Documented date of hire 11/08/2022 #4-Documented date of hire 11/08/2022 #5-Documented date of hire 11/29/2022 Facility records that were submitted for the inspector?s review on 12/15/2022 identified facility staff #s 1-5 as personal care aides. The facility?s Intensive Plan of Correction (IPOC) notes that the ?ED will inspect staff files within three days of hire to ensure compliance. Identified concerns will be corrected.? However, during the review of facility records and interviews conducted on 12/15/2022 the Business Office Manager stated that she did not currently have a system in place to verify the credentials of perspective employees. This interview regarding verification of credentials was continued in the presence of the facility Administrator. Upon request the facility did not submit for the inspector?s review documented evidence that the credentials for staff #s 1-5 had been verified
Plan of Correction:	FACILITY RESPONSE: "For the next five weeks, through February 17, 2023, E.D., a second Virginia Licensed Assisted Living Administrator will review and document the review of new hire credentials prior to new hire starting orientation."
Standard #:	22VAC40-73-440-D
Description:	Based on the review of facility records and interviews conducted with the facility Administrator and facility staff -for private pay individuals, the assisted living facility failed to ensure that the uniform assessment instrument (UAI) is completed as required by 22VAC30- 110. Evidence: Resident #1 The resident?s 11/16/2022 UAI that is also signed by the facility Administrator is not documented to note whether the resident needs help with toileting, transferring, walking and wheeling,
Plan of Correction:	FACILITY RESPONSE: "For the next five weeks, through February 17, 2023, E.D., a second Virginia Licensed Assisted Living Administrator will review and document the review of resident UAIs and IPSs to verify accuracy for all new and updated ISPs."
Standard #:	22VAC40-73-450-C
Description:	Based on the review of facility records and interviews conducted with the facility Administrator and other facility staff the facility has failed to ensure that residents Individualized Service Plans (ISP) are documented to identify all of the required elements. Evidence: For example Resident #1 The residents? 12/02/2022 ISP that was submitted for the inspector?s review notes under the heading Description of Needs: ?Neurocognitive?. Under the heading Description of Services to be Provided to address this need; facility staff notes in part that the resident ?has current or history of frequent difficulty communicating and receiving information; cannot follow instructions.? The document also notes that the resident ?is able to communicate effectively and make her needs known.? Resident #2- The resident?s 11/04/2022 ISP notes meal consumption as a need and the services to be provided is documented as ?Personalize? and ?Resident is on a regular diet.? Facility staff also noted that the resident would be responsible for providing this service. The ISP was not developed to identify how the facility was going to ensure that the prescribed diet was offered to the resident. Resident #4- The resident?s 10/28/2022 ISP notes in part under the heading Description of Needs: ?Diagnosis?; no date identified is documented. There?s a handwritten entry on the ISP under the heading Services to be Provided: ?May experience dizziness may need to elevate legs.? The resident?s ISP however does not identify documented guidance for facility staff to implement that identified possible prevention of the dizziness, triggers that may cause dizziness or the frequency that facility staff elevate the resident?s legs. The ISP for resident #4 also notes Psychosocial as a need and the Services to be Provided notes in part that the resident ?does have current history of hallucinations/delusions.? The ISP is further documented to note that resident #4 is responsible for providing this service.
Plan of Correction:	FACILITY RESPONSE: "For the next five weeks, through February 17, 2023, E.D., a second Virginia Licensed Assisted Living Administrator will review and document the review of resident UAIs and IPSs to verify accuracy for all new and updated ISPs. "
Standard #:	22VAC40-73-450-D
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization communicated and established an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan. Evidence: For example: Resident #-3-Documented date of admission 06/16/2022 The resident?s 06/17/2022 ISP notes ?Resident is on hospice services?, however the residents? care plan is not documented to identify the agreed upon coordinated plan of care between the hospice agency and the facility.
Plan of Correction:	FACILITY RESPONSE: "For the next five weeks, through February 17, 2023, E.D, and a second Virginia Licensed Assisted Living Administrator will review and document the review of hospice resident UAIs and IPSs to verify accuracy. The review and verification of accuracy will be documented on an audit tool."
Standard #:	22VAC40-73-450-F
Description:	Based on the review of facility records and interviews conducted with the facility Administrator and other facility staff, the facility failed to ensure that Individualized service plans were updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: Resident #1- The resident?s 12/02/2022 ISP notes that the resident may Resident #2- The resident?s 11/04/2022 ISP notes that the resident is not able to take medication without assistance. The ISP also notes that the resident self-administers medications per physician orders. The ISP also does not identify specific assessed needs, the services that will be implemented to address the assessed needs. For example-the ISP notes bathing under the heading identified need and ?Bench? is noted under the heading for services to be provided. Resident #3- The resident?s 06/17/2022 ISP notes that the resident is on a regular diet. Under the heading person responsible for providing the services ? facility staff documented ?Resident?. Facility staff assessed the resident on 07/18/2022 as disoriented in all spheres all of the time therefore is not capable of being responsible for her own meals. Facility records identify that the resident resides in the safe and secure environment but the resident?s 06/17/2022 ISP is not documented to note this as a need. Facility staff assessed the resident on 10/25/2022 as being a high fall risk. The resident?s 06/17/2022 ISP was not updated to identify a fall prevention plan. Resident #5-The resident?s 10/04/2022 ISP notes that a behavioral management plan can be in place for the resident, but the ISP is not documented to identify what the plan is or the responsibility of facility staff to implement such a plan. The resident?s ISP is not documented to note that the resident is in need of placement on the safe and secure environment. The Individualized Service Plans for resident # 2, 3, and 5 is not documented to identify all of the resident?s assessed needs.
Plan of Correction:	FACILITY RESPONSE: "For the next five weeks, through February 17, 2023, E.D., a second Virginia Licensed Assisted Living Administrator will review and document the review of resident UAIs and IPSs to verify accuracy for all new and updated ISPs."
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation and interview with facility staff the facility failed to ensure that certain documents related to the terms of the license are required to be posted on the premises of each facility. Evidence: Upon arrival to the facility the findings of the most recent inspection of the facility were not posted. The binder in the lobby of the facility that is supposed to contain the inspection report was empty.
Plan of Correction:	FACILITY RESPONSE: "Concierge team members will verify that the inspection results are in the designated area. ED will verify and document the location of the binder and its contents weekly through February 17, 2023. The POC binder contents and location will be reviewed and documented monthly for the duration of 2023."