VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Emily Green Shores
500 Westmoreland Avenue
Portsmouth, VA 23707
(757) 399-3442

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Nov. 16, 2022

Complaint Related: Yes

Areas Reviewed:

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 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 11/16/22 at 8:35 am to 12:55 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/09/2022 regarding allegations in the areas of: Admission, Retention, and Discharge of Residents and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 33 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: The following additional items were reviewed, staffing schedule, emergency preparedness drills, and practice plan for resident emergencies. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations area of non-compliance with standard(s) or law were: Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint) but identified during the course of the investigation can also be found on the violation notice. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on the record review the facility failed to ensure the Fall Risk Rating (FRR) shall be reviewed and updated when the condition of the resident changes, and after a fall. Evidence: 1. The record for Resident #1 contains a FRR dated 01/09/20. The record did not include documentation of a FRR annually for 2021, 2022, and when the condition of the resident changed to hospice treatment on 10/13/22.
Plan of Correction:	RCC/Administrator will ensure that the Fall Risk Rating is updated with any fall when Hospice Care need is determined and annually.
Standard #:	22VAC40-73-470-F
Complaint related:	No
Description:	Based on the onsite record review the facility failed to ensure when a resident suffers serious accident, injury, illness or medical condition, or there is reason to suspect that such has occurred, the circumstances involved and the medical attention received or refused shall be documented in the resident?s record. The resident?s next of kin, legal representative, and designated contact person shall be notified as soon as possible but no later than 24 hours from the situation and action taken, or if applicable, the resident?s refusal of medical attention. Evidence: 1. The record of Resident #1 contains a progress note dated 10/06/2022 which documents ?the resident has been in bed all morning, refused breakfast and lunch for three days, vital signs were BP 76/50, Pulse 57, and temperature 97.1, and the Resident Care Coordinator contacted the doctor.? There is no documentation in the record that includes the medical attention received or refused. 2. Staff # 1 acknowledged the resident refused to go to the ER on 10/06/22 however the refusal was not documented in the resident?s record. 3. Staff #1 acknowledged the staff on duty did not notify the resident?s legal representative and designated contact person within 24 hours of the resident?s refusal of medical attention.
Plan of Correction:	Administrator met with Medication Aides reviewed company policy to always notify Responsible Party, POA, and Designated Person regarding any change of status at time physician is notified and to always document in Resident?s chart the event that occurred, if vitals not within normal range to always call 911 for professional assistance and document the outcome. On 11/30/2022 Administrator reviewed the Resident?s change of status policy and procedure with all of the nursing team. They are always call the RCC for instructions. The RCC will monitor the direct care staff to ensure they are following said instructions.