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: Sept. 8, 2023

Complaint Related: No

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS

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: An unannounced renewal inspection took place on 09/08/2023 from 8:16 am to 5:25 pm. 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: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: Breakfast, lunch, and an activity were observed. A medication pass observation was completed for two residents. Water temperatures were measured. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at (757) 822-9957 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on the staff record review the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. Evidence: 1. The record for staff #3, hired 10/31/16, did not include documentation of 18 hours of annual training. 2. The record for staff #4, hired 12/14/21, did not include documentation of 18 hours of annual training.
Plan of Correction:	All active direct care employee records will be checked for continuing education. Employees that have not received training will receive formal training. Staff will receive education upon hire and annually. Records will be reviewed by HR or designee monthly. Completion date 10/22/2023
Standard #:	22VAC40-73-250-D
Description:	Based on the staff record review the facility failed to ensure each staff person required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as evidence by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. The record for staff # 3, contains a TB risk assessment completed 03/18/22. The staff record does not contain a TB risk assessment completed after 03/18/22. 2. The record for staff # 4, contains a TB risk assessment completed 11/23/21. The staff record does not contain a TB risk assessment completed after 11/23/21.
Plan of Correction:	All active employee records will be checked for First Aid and CPR certification. Employees that have not received training will receive formal training. Staff will receive training annually. Records will be reviewed by HR or designee monthly. Completion date 10/22/2023
Standard #:	22VAC40-73-260-A
Description:	Based on the staff record review the facility failed to ensure each staff member shall maintain current certification in first aid. Evidence: 1. The record for staff #3, hired 10/31/16, contains a first aid certification with an expiration date of 01/14/22. Staff # 3 record does not contain a current certification in first aid. 2.The record for staff #4, hired 12/14/21, did not contain documentation of certification in first aid.
Plan of Correction:	All active employee records will be checked for First Aid and CPR certification. Employees that have not received training will receive formal training. Staff will receive training annually. Records will be reviewed by HR or designee monthly. Completion date 10/22/2023
Standard #:	22VAC40-73-290-B
Description:	Based on observation the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge. Evidence: 1. Upon arrival at the facility on 9/08/23 at 8:16 a.m. the LI observed a posting that listed the manager on duty as staff #7. Staff #7 was not on site at the facility upon the LI arrival at the facility.
Plan of Correction:	Manager on Duty form was updated. Manager on duty form will be posted at entrances Record on manager on duty schedule will be kept in binder. Executive Director of designee will review binder monthly Completion date 10/22/2023
Standard #:	22VAC40-73-320-A
Description:	Based on the record review the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician and shall include the following: results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form. Evidence: 1. The record for resident #1, admission date of 8/14/23, contains a TB risk assessment completed 1/13/23, which is more than 30 days prior to the resident?s admission date.
Plan of Correction:	All active resident records will be checked for active TB assessment. All residents, not within compliance date will be screened. Resident records will be updated pending screening. Records will be reviewed by Nurse Manager or designee monthly Completion date 10/22/2023
Standard #:	22VAC40-73-430-H-1
Description:	Based on the record review the facility failed to ensure at the time of discharge, the assisted living facility shall provide to the resident, and as appropriate, his legal representative and designated contact person a dated statement. Evidence: 1. The record for resident #7, discharge date of 05/22/23, did not contain documentation of a dated discharge statement.
Plan of Correction:	Discharge documentation will be sent to resident/POA via certified mail. Staff will receive in service regarding resident discharge and documentation Residents discharged within the last 6 months will be reviewed for accurate discharge information. Records will be reviewed by Executive Director or designee monthly Completion date 10/22/2023
Standard #:	22VAC40-73-490-A
Description:	Based on the record review the facility failed to ensure for residents who meet the criteria for assisted living care, if the facility employs a licensed health care professional who is on site on a full-time basis, a licensed health care professional practicing within the scope of his profession, shall provide health care oversight at least every six months. Evidence: 1. The facility record contains documentation of a health care oversight dated 02/07/23-02/09/23 and 02/14/23-02/16/23. The facility did not provide record of a health care oversight completed six months after the date of 02/16/23.
Plan of Correction:	Nurse Manager will complete healthcare oversight Nurse Manager will receive education on timeliness of healthcare oversight within regulations Consultation Company will review healthcare oversight for accuracy upon completion Completion date 10/22/2023
Standard #:	22VAC40-73-550-G
Description:	Based on the staff record review the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each staff person. Evidence: 1. The record for staff #3 contains an annual review of rights and responsibilities dated 01/21/22. The staff record does not contain an annual review of rights and responsibilities of residents completed after the date of 01/21/22. 2. The record for staff #4 contains an annual review of rights and responsibilities dated 12/24/21. The staff record does not contain an annual review of rights and responsibilities of residents completed after the date of 12/24/21.
Plan of Correction:	All active resident files will be reviewed for annual signature. All active Resident/POA will receive copy of resident rights once signed. Executive Director or designee will review monthly. Date of completion 10/22/2023
Standard #:	22VAC40-73-970-E
Description:	Based on the facility record review the facility failed to ensure a record of the required fire and emergency evacuation drills shall include: the method used for notification of the drill; any special conditions stimulated; weather conditions. Evidence: 1. The facility?s fire dill records dated 06/09/23, 07/18/23, and 8/29/23 did not include the method used for notification, any special conditions stimulated, and the weather conditions.
Plan of Correction:	Maintenance Director was educated on regulations for fire and emergency evacuation drills Maintenance Director provided with adequate fire drill forms within regulations. Maintenance Director will conduct Fire and emergency evacuation drills on various shifts Fire and emergency evacuation drills will be reviewed by Executive Director monthly Completion date 10/22/2023
Standard #:	22VAC40-73-990-C
Description:	Based on the onsite review the facility failed to ensure at least every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years. Evidence: 1. The facility did not provide documentation of staff participation in an exercise in which the procedures for resident emergencies were practiced every 6 months.
Plan of Correction:	Maintenance Director was educated on regulations for fire and emergency evacuation drills Maintenance Director provided with adequate fire drill forms within regulations. Maintenance Director will conduct Fire and emergency evacuation drills on various shifts Fire and emergency evacuation drills will be reviewed by Executive Director monthly Completion date 10/22/2023