VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Chesapeake Place
1500 & 1508 Volvo Parkway
Chesapeake, VA 23320
(757) 548-0808

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: June 28, 2023

Complaint Related: Yes

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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-80 THE LICENSE 22VAC40-80 COMPLAINT INVESTIGATION

Technical Assistance:

Weekly Breakfast Menu

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: An unannounced complaint inspection took place on 6/28/2023 from 11:19am to 5:00 pm. 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 06/22/2023 regarding allegations in the areas of: Personnel, Resident Care and Related Services, Staffing and Supervision, and the Safe, Secure Unit. Number of residents present at the facility at the beginning of the inspection: 95 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: An observation of lunch was completed and a review of the facility?s staffing schedule, and smoking policy was completed. Additional Comments/Discussion: None 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: Personnel, Resident Care and Related Services, and Safe, Secure Unit. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1130-C
Complaint related:	Yes
Description:	Based on staff interview and review of the staff schedule the facility failed to ensure during night hours, the following number of direct care staff members shall be awake and on duty at all times in each special care unit and responsible for the care and supervision of the residents: when 23 to 32 residents are present at least three direct care staff members. Evidence: 1. The staffing schedule for the safe, secure unit for June 2023 documented only two direct care staff members scheduled for the shift of 11pm to 7am from 06/01/2023 through 06/26/2023. 2.During an interview with staff # 5, the staff confirmed only two direct care staff members were scheduled, and awake on duty in the safe, secure unit for the 11pm to 7 am shift from 06/01/2023 through 06/26/2023. The staff confirmed the facility census in the safe secure unit has been in the range of 23 to 32 residents for the month of June 2023, and the census as of 06/28/23 was 29 residents.
Plan of Correction:	Corrective action has been taken to help to enhance staffing and to ensure the deficient practice does not recur, multiple clinical staff were hired for all three shifts pending the completion their background checks, orientation, and training process.
Standard #:	22VAC40-73-1150-A
Complaint related:	Yes
Description:	Based on staff interview, the facility failed to ensure doors that lead to unprotected areas be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates for residents residing in a safe, secure environment. Evidence: 1. The record for residents #1 and #2 contains a progress noted dated 06/06/23 that documents ?at approximately 6:30 pm resident was able to make it out of the Memory care building, the resident was found on the sidewalk by the Assisted Living facility.? 2. During an interview with staff #5, the staff confirmed residents #1 and #2 exited the safe, secure unit building through the front door that leads to an unsecured parking lot, the door was opened and not locked when the residents exited the building.
Plan of Correction:	Maintenance fixed door and changed code All exits in memory care were checked for elopement risks Maintenance Director or designee will perform weekly checks on memory care exits. Executive Director or designee will sign off on audit tool weekly
Standard #:	22VAC40-73-40-B
Complaint related:	No
Description:	Based on observation the licensee failed to ensure that the current license is posted in the facility in a place conspicuous to the residents and the public. Evidence: 1. During a tour of the facility on 06/28/2023 the Licensing Inspector (LI) observed the previous license effective 10/01/2021-09/30/2022 to be posted in the facility. The current license, effective 10/01/2022-09/30/2023 was not posted in the facility.
Plan of Correction:	Current License Posted
Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on the record review 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: 1. The record for resident #4 contains a progress note dated 06/09/2023 documenting ?resident found coughing and admits to feeling short of breath, resident sent out via 911 for observation and treatment.? The facility did not notify the regional licensing office of the resident being sent to the hospital for observation and treatment. 2. The record for residents #1 and #2 contains a progress noted dated 06/06/23 that documents ?at approximately 6:30 pm resident was able to make it out of the Memory care building, the resident was found on the sidewalk by the Assisted Living facility.? The facility did not notify the regional licensing office within 24 hours of the incident of the residents exiting and wandering outside of the safe, secure unit. 3. The record for resident #5 contains a progress note dated 06/10/23 documenting ?resident was sent out to ER due to a fall, staff found resident on the floor in the dining room with a laceration in front of the resident?s head.? The facility did not notify the regional licensing office of the resident visit to the ER due to a fall, and laceration in front of the resident?s forehead.
Plan of Correction:	100% of Staff will be in serviced to inform Nursing Management of ALL residents sent out to the hospital. Nurse Management or designee will perform audit of all residents sent out for the month of July, moving forward, with notification to Licensing Office.
Standard #:	22VAC40-73-130-A
Complaint related:	Yes
Description:	Based on interviews and the staff record review the facility failed to ensure all staff who are mandated reporters under code 63.2-1606 of the Code of Virginia shall report suspected abuse, neglect, or exploitation of residents in accordance with that section. Evidence: 1. The record for staff #1 contains documentation dated 03/19/2023 to include resident #6 complained of being verbally abused by staff #1. The documentation included ?resident #6 stated that staff #1 talked to her very rude and disrespectful, wasn?t giving the resident, the resident?s medication, and was yelling at the resident.? 2. During an interview with staff #4, #6, and #7, the staff did not confirm, and did not provide documentation to confirm the facility reported the suspected abuse to Adult Protective Services (APS). 3. During an interview on 06/28/23 with resident #6, the resident informed the Licensing Inspector (LI) that during the weekend of March 17, and March 18 2023 staff #1 was ?verbally disrespectful? to the resident, and staff #1 ?refused? to give the resident, the resident?s eyedrops medication. 3. During a call on 07/13/2023 with the City of Chesapeake APS Worker, the worker was not able to locate a report of suspected abuse made for resident #1.
Plan of Correction:	Affected resident interviewed regarding safety, employee removed from unit. All residents and/ or POA will be interviewed regarding abuse and safety of facility. 100% of Staff will be in serviced regarding abuse and reporting.