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: June 21, 2023

Complaint Related: Yes

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: On 06/21/2023 approximate time 9:33a.m-5:03p.m. On 07/21/2023 approximate time 08:32a.m-6:50p.m. 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 02/17/2023 regarding allegations in the areas of administration and administrative services, personnel, resident care and related services and buildings and grounds. Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 4 Observations by licensing inspector: Technical assistance offered. Additional Comments/Discussion: 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(s) of non-compliance with standard(s) or law were: Administration and Administrative 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at angeal.r.reaves@dss.virginia.gov Violation Notice Issued: Yes

Violations:

Standard #:	22VAC40-73-40-A
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted the licensee failed to ensure compliance with the facility's own policies and procedures. Evidence: Resident #1: On 01/21/2023 the facility submitted an incident report to the regional licensing office informing that resident #1 and the resident?s power of attorney reported to facility staff that $250 was missing out of the resident?s purse. Facility policy OP 23-1.c SafeKeeping of Resident Property that was submitted for the inspector?s review on 06/21/2023 notes under the heading High Value Items: ?Our Executive Director must report any property loss reasonably valued by the Executive Director at over $100 to the local law enforcement agency within 36 hours of our discovery of the loss.? 01/30/2023: Responding to the inspector?s email inquiry whether a police report was made regarding the 01/21/2021 incident report (theft allegations) the facility Administrator responded ?No ma?am. We did not file a police report as we could not substantiate the allegation of theft. Resident and family were informed of that option during our initial meeting on Saturday, January 21st and again as I shared our conclusion.? 06/21/2023: During interviews while onsite at the facility the facility Administrator stated that he did not file a police report regarding the $250 theft allegations. The facility did not make a report to the local law enforcement agency within 36 hours of being made aware of the theft as the facility?s policy required.
Plan of Correction:	FACILITY'S RESPONSE: "Immediate: The Executive Director at the time of the incident is no longer with the facility. The facility department heads educated on facility policy of reporting loss of property to law enforcement agency within 36 hours of discovery, OP 23-Safekeeping of Resident Property Policy. Audit: The Executive Director or designee audit incidents and grievances of lost property for timely reporting. Systemic: New Anthology Executive Director was hired, who was trained on the policy and procedure for reporting to ensure compliance. The Executive Director will provide monthly re-education to Department heads of, OP 23-Safekeeping of Resident Property Policy Monitoring: Executive Director or designee will review all grievances and log them appropriately in the required location and documented responses will be given to the appropriate individuals and/or departments. For any concern regarding safe keeping of resident property the Executive Director will retain a copy of all notifications made to local police departments and reviewed monthly as part of the continued quality improvement meetings."
Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: Resident #1 Facility staff #1 stated during the 07/14/2023 interview that the review of facility progress notes document confirmed that the resident had a fall on 01/01/2023 and was sent out to the local hospital A copy of this document will be sent to the licensee/provider for signature. Inspector Name: Angela Rodgers-Reaves Date Violation Notice Issued: 7/14/2023 emergency medical intervention. The resident never returned to the facility. Upon request the facility did not submit documented evidence that the 01/01/2023 incident regarding resident #1 was reported the regional licensing office as required.
Plan of Correction:	FACILITY'S RESPONSE: "Immediate: The Executive Director at the time of the incident is no longer with the facility. The Director of Health and Wellness educate Medication Aides (Medication Manager) and LPNs of responsibility to notify the DHW or Executive Director of major incidents negatively affecting the resident to include falls with emergency medicine intervention immediately. Audit: The Director of Health and Wellness audit the incident reports for any major incidents to include falls with emergency medicine intervention and notification to regional licensing office. Systemic: New Anthology Executive Director was hired, who was trained on the policy and procedure for reporting to DSS ensure compliance. The Director of Health and Wellness has provided in?service training to all Medication Managers and LPNs on policy and Executive Director/Director of Health and Wellness 7/26/2023 procedure related to reporting major incidents that has negative effects or threaten the health, safety, or welfare of any resident immediately to the Director of Health and Wellness or Executive Director. This will be ongoing with new hires and completed quarterly. Monitoring: Director of Health and Wellness or designee will review incident reports five times weekly to ensure appropriate reporting is completed timely. The Executive Director will subsequently audit the incident reports and provide an additional sign-off to ensure that all required notifications are made."