VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Mennowood Retirement Community
13030 Warwick Blvd.
Newport news, VA 23602
(757) 249-0355

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: March 14, 2023 , March 17, 2023 and March 22, 2023

Complaint Related: No

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 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 An unannounced on-site renewal inspection was conducted on 3-14-23 (Ar 08:35 a.m./dep 3:45 p.m) and 3-17-23 (Ar 09:00 a.m./dep 3:45 p.m.). The facility census on day 1 was 93. A tour of the facility was conducted, staff and resident interviews, resident records reviewed and medication pass observation was conducted. A review of staff records and resident records were conducted on day 2. Emergency preparedness documents and internal audit documents were reviewed. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure in accordance with 63.2-1805 D Code of Virginia, it did not admit or retain individuals with any prohibitive conditions with required documentation for a resident. Evidence: 1. On 3-14-23, resident #6?s record documented resident administered Zoloft. The resident?s current physical order sheet (POS) in the record noted the medication start date was noted as 9-20-22. The record did not include a psychotropic treatment plan for this medication. 2. Staff #2 acknowledged the record did not include a psychotropic treatment plan.
Plan of Correction:	I. Corrective Action: Physician Order for the Psychopharmacologic medication treatment plan for resident #6 was corrected. II. How to Identify: Director of nursing or designee will do an audit of resident charts to make sure the medication treatment plan aligns with the physician order sheet. III. Systemic Changes: Director of Nursing or designee will monitor new orders and psychotropic treatment plan and treatment established. IV. Monitoring Process: Director of Nursing or designee will ensure completion of audits are done within 30 days of admission. Director of Nursing or designee will audit new files monthly for two months then ongoing as needed. Nursing staff will be in-service on the psychotropic treatment plans. V. Completion Date: April 31, 2023
Standard #:	22VAC40-73-450-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee and by the resident or the legal representative for three of ten records reviewed. Evidence: 1. On 3-14-23, resident #1?s ISP dated 10-17-22, resident #2?s ISP dated 3-7-23 and resident #5?s ISP dated 2-27-23 were not signed and dated by the resident or the legal representative. 2. Staff #2 acknowledged the ISPs were not signed and dated by the resident and/or legal representative.
Plan of Correction:	I. Corrective Action: Care plans will be signed at the time of care plan meeting or documentation of telephone or zoom meetings. If unable to obtain signature an email will be sent and/or documentation will be noted. II. How to Identify: Director of Nursing or designee will audit charts and obtain signatures on care plans. III. Systemic Changes: Director of Nursing or designee will monitor and assure care plans have signatures upon completion of meeting with resident/family members. IV. Monitoring Process: Director of Nursing or designee will ensure signatures are on care plans or documentation acquired. V. Completion Date: April 31, 2023
Standard #:	22VAC40-73-860-G
Description:	Based on observations and staff interviewed, the facility failed to ensure hot water at taps available to residents was maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F. Evidence: 1. On 3-14-23, during a tour of the facility with staff #8, the water temperature in the bathroom in room #105 was 121 degrees F and the temperature in the kitchen was 123 degrees F. 2. Staff #8 acknowledged the water temperatures were outside the required range.
Plan of Correction:	I. Corrective Action: Maintenance Director or designee will do a complete water temperature check in all rooms, kitchen, and common areas. II. How to Identify: Maintenance Director or designee will make sure rooms closest to the water heaters are checked monthly. III. Systemic Changes: Maintenance Director will create a log of rooms, kitchen, and common area temperatures. IV. Monitoring Process: Maintenance Director or designee will do a complete water temperature check in rooms, kitchen, and common areas and then continue to do monthly random audits of resident rooms and common areas. V. Completion Date: April 31, 2023