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: July 7, 2023

Complaint Related: No

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: On 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. 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: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 5 Observations by licensing inspector: non compliance cited Additional Comments/Discussion: 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 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 #:	22VAC40-73-120-A
Description:	Based on the review of facility records and interviews conducted with facility staff the facility failed to ensure that the orientation and training required occurred within the first seven working days of employment. Evidence: Facility staff #3- Documented date of hire 05/31/2023 Upon request the facility did not submit for the inspector?s review documented evidence that staff #3 received orientation within the first seven days or since employment.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-250-D
Description:	Based on the review of facility records and interviews conducted with facility staff the facility failed to ensure that each staff person was evaluated annually and submitted the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The most recent tuberculosis test on file for the resident that was submitted for the inspector?s review on 07/07/2023 is dated 01/18/2022 Evidence: Facility staff #4- Documented date of hire 10/28/2021
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-260-A
Description:	Based on the review of facility records and interviews conducted with facility staff the facility failed to ensure that all direct care staff member maintained current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. To be considered current, first aid certification from community colleges, hospitals, volunteer rescue squads, or fire departments shall have been issued within the past three years. Evidence: Facility staff #2- Documented date of hire 12/13/2022 Upon request the facility did not submit for the inspector?s review documented evidence that staff #2 has current certification in first aid.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-A
Description:	Based on the review of facility records and interviews conducted with facility staff the facility failed to ensure that all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The UAI must be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition. Evidence: Resident #1- Documented date of admission 07/05/2023 Upon request on 07/07/2023 the facility did not submit for the inspector?s review documented evidence that a UAI was completed for the resident. The facility submitted the resident?s initial UAI on 07/18/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-A
Description:	Based on the review of facility records and interviews conducted with facility staff the facility failed to ensure that on or within seven days prior to the day of admission, a preliminary plan of care is developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: Resident #1- Documented date of admission 07/05/2023 The residents? health and physical examination report dated 06/23/2023 notes under the heading Other ?nonpharmacological interventions for sundowning?. 07/06/2023: The facility submitted an incident report informing that at 6:30p.m on 07/05/2023 without escort, the resident left the memory care environment and the courtyard of the facility and was returned without incident or injury. 07/07/2023: During staff interviews and the review of facility records while onsite at the facility the facility did not submit for the inspector?s review documented evidence that a preliminary ISP (Individualized Service Plan) had been developed for the resident prior to or since admission on 07/05/2023. Resident #9- Documented date of admission 06/08/2023 Upon request while onsite on 07/07/2023 the facility did not submit for the inspector?s review documented evidence that a preliminary plan of care had been developed for the resident. The 06/08/2023 ISP on file for resident #9 is from a different assisted living facility.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-D
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization must communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each must be included on the individualized service plan. Evidence: Resident #2- The residents? 02/17/2023 ISP that was submitted for the inspector?s review notes in part that the hospice nurse visits weekly and as needed and care aide visits twice weekly. The resident?s 02/17/2023 ISP does not identify a description of services being provided by the hospice agency and is not signed and dated by hospice staff.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-550-G
Description:	interviews conducted the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities are reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person. Evidence of this review must include the date of the review and must be filed in the staff person's record. Evidence: Facility staff # 4- Documented date of hire 10/28/2021 Upon request the facility did not submit for the inspector?s review documented evidence that an annual review of resident rights had been conducted with staff #4. The resident?s rights document on file at the facility for staff #4 is not dated.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-560-F
Description:	Based on observation and interviews conducted the facility failed to ensure that all resident records are treated confidentially. Evidence: While on site in the memory care environment of the facility on 07/07/2023 the inspector observed that the resident?s personal information was not being treated confidentially. The inspector observed the following: -An orange binder being stored on a table that recorded the residents? showers and any skin integrity issues. -A yellow binder that recorded the residents weight and other vitals.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-640-A
Description:	Based on the review of facility records and staff interviews conducted the facility failed to ensure that methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order were implemented. Resident #1 Documented date of admission 07/05/2023 07/07/2023: During observation of the noon time medication pass in the memory care environment the inspector was informed that resident #1 was admitted to the facility on 07/05/2023 and no medications have been administered to the resident since admission because the medication orders for the resident had not been entered into the facility?s electronic medication administration records (MAR) system. Facility staff # 1, 2 and 3 confirmed during the ongoing staff interviews conducted on 07/07/2023 that the medications were not administered as the facility had not confirmed the physician?s orders to make the orders active on the resident?s MAR. The residents? MAR charting for July 2023 that was submitted for the inspector?s review on 07/18/2023 revealed that for nine days beginning 07/05/2023 through 07/13/2023 the resident was not administered 135 dosages of his prescribed medications.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-880-C
Description:	Based on observation and staff interviews the facility failed to ensure that the temperatures in all areas used by the residents, including residents? bedrooms and common areas must not exceed 80?F. Evidence: During the walk through of the 3rd floor of the facility on 07/07/2023 at approximately 8:56a.m the inspector observed the thermostat reading in the facility?s salon to be 102.9 degrees.
Plan of Correction:	Not available online. Contact Inspector for more information.