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: 06/21/2023 Beginning approximately 9:33-5:03p.m 07/07/2023 Beginning approximately 8:32a.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 06/13/2023 regarding allegations in areas of Personnel, Resident care and related services and Medication management. Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 7 Number of interviews conducted with residents: Number of interviews conducted with staff: 4 Observations by licensing inspector: No resident concerns noted. 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. 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 angela.r.reaves@dss.virginia.gov Violation Notice Issued: Yes

Violations:

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. On 06/16/2023 the facility Administrator submitted a resident incident report to the licensing office informing that on ?June 8, 2023: a quality assurance audit of our medication administration records revealed that on Thursday June 8th, six of our Virtue Memory Care residents were not administered their mid-day medications.? The facility did not submit an incident report to the regional licensing office within 24 hours of the incident as required.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-J
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that when a medication error occurred that the resident's physician of record and family member or other responsible person were notified as soon as possible. Evidence: Residents 1-7 Upon request the facility did not submit for the inspector?s review facility documentation that verified that the residents physician and responsible parties were notified that the noon time medications were not administered to the residents on 06/08/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.