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: May 31, 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 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

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 05/31/2023 from 8:30 am to 4:00 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: 28 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: 2 Observations by licensing inspector: 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. Additional Comments/Discussion: None 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 #:	22VAC40-73-310-H
Description:	Based on the record review the facility failed to ensure in accordance with 63.2-1808 of the Code of Virginia, assisted living facilities shall not admit or retain individuals with any of the following conditions or care needs: psychotropic medications without appropriate diagnosis and treatment plans. Evidence: 1. The record for resident #5 contains a physician order dated 05/08/23 to include ?Quetiapine 25mg, take one tablet by mouth every day for schizophrenia; Lorazepam 0.5mg take one table by mouth three times daily as needed for anxiety.? The record does not contain documentation of a treatment plan for the psychotropic medications, Quetiapine and Lorazepam.
Plan of Correction:	RCC & Compliance, LPN will review all resident charts who are taking psychotropic medications quarterly to ensure their physician has reviewed chart and updated treatment plan
Standard #:	22VAC40-73-380-B
Description:	Based on the record review the facility failed to ensure the personal and social information required in subsection A of this section (allergies, and information concerning Do Not Resuscitate (DNR) Orders shall be placed in the person's record and kept current. Evidence: 1. Resident #1?s personal and social information documented ?N/A? in the section for DNR status. The resident?s record contains a DNR order dated 05/27/21. 2. Resident #4?s personal and social information documented the resident?s allergies as ?none known.? The resident?s ISP dated 08/12/22 documents the resident is allergic to adhesive tape. The resident?s physical exam dated 08/10 22 documents the resident is allergic to tape.
Plan of Correction:	RCC & Compliance will review and ensure all Resident?s social data forms are updated with any changes to status codes, allergies, contact information and change of physician quarterly to ensure accuracy
Standard #:	22VAC40-73-490-A-2
Description:	Based on the record review the facility failed to ensure for residents who meet the criteria for assisted living, a licensed health care professional shall provide health care oversight at least every three months and all residents shall be included at least annually in healthcare oversight. Evidence: 1. The record for resident #1, does not contain documentation of a health care oversight completed during the timeframe of 05/12/22- 05/31/23. The resident?s Uniform Assessment Instrument (UAI) dated 11/23/22 documents the resident meets the criteria for assisted living care. 2. The record for resident #3, does not contain documentation of a health care oversight completed during the timeframe of 05/12/22- 05/31/23. The resident?s Uniform Assessment Instrument (UAI) dated 12/16/22 documents the resident meets the criteria for assisted living care. 3. The facility?s health care oversight dated 06/15/22 and 01/09/23 did not include documentation the health care oversight included the record review for residents #1 and #3. 4.During an interview with staff #4, the staff confirmed the facility does not employ a licensed health care professional on a full-time basis and the dates of the most recent health care oversight completed are 06/15/22 and 01/09/23.
Plan of Correction:	Administrator contracted new oversite nurse to provide oversites quarterly to ensure all Residents charts are reviewed
Standard #:	22VAC40-73-640-A
Description:	Based on observation the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated medications. Evidence: 1. During the medication cart observation with staff # 5 the following expired medications were observed on the medication cart: Cetirizine Hydrochloride 10mg expired 01/2023 for resident #7. 2.The resident?s Medication Administration Record documents the resident was administered Cetirizine Hydrochloride 10mg the dates of 05/25/23 through 05/31/23. Staff #5 confirmed the Cetirizine Hydrochloride administered to the resident was from the bottle labeled with an expiration date of 01/2023.
Plan of Correction:	Compliance Nurse, LPN orientated RCC and Medication Aides to comply with medication policy to review all medications upon new arrival and medication administration for expiration dates