VIRGINIA DEPARTMENT OF SOCIAL SERVICES

LAV'M Adult Residence
912 S. Battlefield Blvd.
Chesapeake, VA 23322
(757) 546-2810

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: March 28, 2023

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Technical Assistance:

Ensure weekly breakfast menu is current. Staffing schedule should clearly indicate the staff person in charge for each shift.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 03/28/2023 at 08:32 am until 03:45 pm. 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: 21 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: Lunch and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on the record review the facility failed to ensure in a facility licensed for both residential and assisted living care, direct care staff who are licensed health care professionals or certified nurse?s aides shall attend at least 12 hours of annual training. Evidence: 1. The record for staff #1, a certified nurse?s aide, hire date 08/31/21 documents 10.5 hours of annual training during the timeframe of 08/31/21-08/31/22.
Plan of Correction:	The Licensee and the Administrator assure that direct care staff who are licensed health care professionals or CNAs shall attend at least 12 hours of annual training. The licensee and the Administrator further assure that training hours are correctly added and documented, and that staff attend the scheduled trainings offered.
Standard #:	22VAC40-73-250-D
Description:	Based on the record review the facility failed to ensure each staff person required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as evidence by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. The record for staff # 2, contains documentation of a TB risk assessment completed 02/05/22. There is no documentation of an annual TB risk assessment completed after 02/05/22.
Plan of Correction:	Licensee and the Administrator assure that each staff will be evaluated annually and submit results of a risk assessment documenting individual is free from Tuberculosis (TB) in a communicable form as evidenced by the completion of the current form published by DOH.
Standard #:	22VAC40-73-260-C
Description:	Based on the record review the facility failed to ensure a listing of all staff who have current certification in first aid or CPR shall be posted in the facility, Evidence: 1. During a tour of the facility a listing of all staff who have current certification in first aid or CPR was not observed to be posted in the facility. 2. Staff #4 acknowledged a listing of all staff who have current certification in first aid or CPR was not posted in the facility.
Plan of Correction:	The Licensee and the Administrator assure that a listing of all staff who have current First Aid and CPR are posted in the facility.
Standard #:	22VAC40-73-290-B
Description:	Based on observation the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. During a tour of the facility a posting of the on-site person in charge was not observed to be posted in the facility. 2. Staff #4 acknowledged a posting of the on-site person in change was not posted in the facility.
Plan of Correction:	The Licensee and the Administrator assure that the name of the current on-site person in charge is posted in the facility that is conspicuous to the residents and the public.
Standard #:	22VAC40-73-320-A
Description:	Based on the record review the facility failed to ensure within 30 days preceding admission, a person shall have a physical examination by an independent physician. Evidence: 1. The record for resident #1, admission date of 02/18/22, contains a physical examination dated 12/17/2021 which is more than 30 days prior to the resident?s admission date.
Plan of Correction:	The Licensee and the Administrator assure that any physical examinations for residents should not exceed 30 days prior to the resident?s admission date, moving forward. The Licensee and the Administrator further assure that this will be obtained and checked with utmost discretion.
Standard #:	22VAC40-73-320-B
Description:	Based on the record review the facility failed to ensure a risk assessment for (TB) shall be completed annually on each resident as evidenced by completion of the current screening form published by the Virginia Department of Health or form consistent with it. Evidence: 1. The record for resident #1 contains a risk assessment for TB dated 01/20/22. The resident?s record does not contain an annual risk assessment for TB completed after 01/20/22.
Plan of Correction:	The Licensee and the Administrator assure that a risk assessment for TB shell be completed annually for each resident as evidenced by completion of the current screening form published by the Virginia Department of Health.
Standard #:	22VAC40-73-440-A
Description:	Based on the record review the facility failed to ensure the Uniform assessment instrument (UAI) shall be completed at least annually. Evidence: 1. The record for resident # 1 contains an UAI dated 01/11/22. The resident?s record does not contain an UAI completed annually after 01/11/22. 2. The record for resident #5 contains an UAI dated 01/06/22. The resident?s record does not contain an UAI completed annually after 01/06/22.
Plan of Correction:	The Licensee and the Administrator assure that all Uniform Assessment Instrument (UAI) shall be completed at least annually.
Standard #:	22VAC40-73-450-E
Description:	Based on the record review the facility failed to ensure the ISP shall be signed and dated by the resident or his legal guardian. Evidence: 1. Resident #1?s ISP dated 02/18/22 was not signed and dated by the resident or the legal guardian. 2. Resident # 3?s ISP dated 07/28/22 was not signed and dated by the resident or legal guardian. 3. Resident #4?s ISP dated 05/23/22 was not signed and dated by the resident or legal guardian. 4. Resident #5?s ISP dated 01/06/22 was not signed and dated by the resident or legal guardian.
Plan of Correction:	The Licensee and the Administrator assure that Individualized Services Plan for Residents are duly signed and dated by the residents themselves or by their legal guardian.
Standard #:	22VAC40-73-450-F
Description:	Based on the record review the facility failed to ensure the Individualized Service Plan (ISP) shall be reviewed and updated at least once every 12 months. Evidence: 1.The record for resident # 1 contains an ISP dated 02/18/22. The resident?s record does not contain an ISP completed annually after 02/18/22. 2. The record for resident #5 contains an ISP dated 01/06/22. The resident?s record does not contain an ISP completed annually after 01/06/22.
Plan of Correction:	The Licensee and the Administrator assure that all residents? Individualized Services Plan will be completed and or updated annually.
Standard #:	22VAC40-73-660-A
Description:	Based on observation the facility failed to ensure medications shall be stored in a manner consistent with current standards of practice and the storage area shall be locked and the individual responsible for medication administration shall keep the keys to the storage area on his person. Evidence: 1. During a tour of the facility with staff #2 the medication cart was observed to be unlocked. 2. The key to the medication cart was observed to be inserted into the lock/unlock device on the medication cart. Staff #2 was observed to remove the keys and place them in her possession. The record for staff # 2 does not contain a license provided by the Commonwealth of Virginia to administer medications or a license as a medication aide with the Virginia Board of Nursing. 3. Staff #2 informed the inspector, the staff person responsible for medication administration was not onsite at the facility during this observation.
Plan of Correction:	The Licensee and the Administrator assure that medications shall be stored in a manner consistent with current standards of practice and the storage area shall be locked, and the individual responsible for the medication administration shall keep the keys to the storage are on his or her person. Staff responsible for medication is made aware of the situation and assures that this will not happen again moving forward.
Standard #:	22VAC40-73-990-C
Description:	Based on the record review the facility failed to ensure at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Evidence: 1. The facility?s last practice of plan for resident emergencies is dated 08/14/22. The facility did not provide evidence of a practice of plan for resident emergencies being completed six months after 08/14/22.
Plan of Correction:	The Licensee and the Administrator assure that all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Both further assure that employees and residents participate at least once every 6 months.
Standard #:	22VAC40-90-40-B
Description:	Based on the onsite record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each staff person. Evidence: 1. The record for staff #2, hire date 08/17/2022, contains a criminal history record report dated 10/24/22. 2. The record for staff #1, hire date 08/13/21, contains a criminal history record report dated 11/12/21.
Plan of Correction:	The Licensee and the Administrator assure that criminal history record will be obtained on or prior to the 30th day of employment for each staff person. The licensee and Administrator assure and ensure that results of Criminal Record Report will be received first before staff employment moving forward.