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: 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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 COMPLAINT INVESTIGATION

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 09/08/2023 from 8:16 am to 5:25 pm. A complaint was received by VDSS Division of Licensing on 09/01/23 regarding allegations in the area(s) of: Resident Care and Related Services 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. 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: Resident Care and Related Services 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) 822-9957 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-440-A
Complaint related:	Yes
Description:	Based on the record review and staff interview the facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed prior to admission, and at least annually. Evidence: 1. The record for resident #4, contains a UAI dated 10/18/21. The resident?s record does not contain a UAI completed annually after 10/18/21. 2. The record for resident #6, contains a UAI dated 03/24/22. The resident?s record does not contain a UAI completed annually after 03/24/22. 3. The record for resident #10, admission date 08/10/23, did not contain a UAI.
Plan of Correction:	Clinical staff will receive education/in-service regarding UAI regulations. All active resident charts will be reviewed for UAI?s dated within compliance All residents UAI?s, not within compliance date will be updated. Resident UAI?s will be reviewed by Nurse Manager or designee monthly Completion date 10/22/2023
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	The facility failed to ensure the Individualized Service Plan (ISP) shall be reviewed annually and updated at least once every 12 months. Evidence: 1.The record for resident #6, contains an ISP completed 03/28/22. The resident?s record does not contain an ISP completed at least 12 months after 03/28/22.
Plan of Correction:	Not available online. Contact Inspector for more information.