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 and July 7, 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 07/07/2023 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 03/29/2023 regarding allegations in the areas of staffing and supervision and resident care and related services. 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: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 7 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 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 It was revealed during the complaint investigation that the facility did not submit an incident report to the regional licensing office regarding the 03/16/2023 major incident that required outside emergency medical intervention.
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 that require outside emergency medicine intervention immediately. Audit: The Director of Health and Wellness audit the incident reports for any major incidents with emergency medicine intervention with notification to regional licensing office. Systemic: New Anthology Executive Director was hired, who was trained on the policy and procedure for reporting to DSS to ensure compliance. The Director of Health and Wellness has provided in?service related to reporting major incidents that has negative effects or threaten the health, safety, or welfare of any resident requiring emergency medical intervention 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 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."