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: Dec. 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

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 12/08/2023 from 8:50 am to 11:45 am. A self-reported incident was received by VDSS Division of Licensing on 11/06/23. 11/22/23, and 11/23/23 regarding allegations in the area(s) of: Resident Care and Related Services, and the Safe, Secure Environment. 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: 77 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 6 Observations by licensing inspector: Lunch and an activity were observed. The staffing schedule was reviewed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. A violation notice was issued; any violation(s) not related to the self-report 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. 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 #:	22VAC40-73-1150-A
Description:	Based on record review, and 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. Resident?s #1 incident report dated 11/09/23 documents ?on 11/05/23 @ 12:40 pm, dietary staff entered the memory care unit, staff didn?t ensure the door was securely locked and resident #1 left the unit and sat on the front porch. 10 minutes later, resident #1 was discovered by dietary staff on the front porch.? 2. During an interview with staff #1, staff #1 acknowledged on 11/05/23, resident #1 exited the safe secure unit through an unlocked front door leading to the facility?s parking lot. The front door leads to an unsecured parking lot area. 3. Resident?s #1 assessment for serious cognitive impairment dated 05/16/23 documents the resident diagnosis as the following: severely impaired cognitive and memory due to Alzheimer?s Dementia.? Resident?s #1 physical examination dated 05/16/23 documents the resident diagnosis as ?Alzheimer?s Dementia.?
Plan of Correction:	All staff will receive education and training regarding resident elopement. Maintenance Director and/or designee will perform elopement drills, monthly Maintenance Director and/or designee will perform exit door checks in memory care unit weekly Elopement drills and exit checks will be reviewed by Executive Director or designee monthly Executive Director and Maintenance Director 01/31/2024
Standard #:	22VAC40-73-1150-B
Description:	Based on staff interview, and the record review the facility failed to ensure there shall be protective devices on windows in common areas accessible to residents to prevent windows from being opened wide enough for a resident to crawl through. Evidence: 1. During an observation on 12/08/23, the Licensing Inspector (LI) observed a window located in the common area in the safe, secure unit to be missing the bottom frame window glass. The LI observed cardboard held in place by duct tape located in the area where the window glass was missing. The window did not contain a protective device to prevent the window from being opened. 2. During an interview with staff #3, staff #3 stated on 11/23/23 resident #2 broke the window glass located in the common area/dining area, and staff #3 used cardboard and duct tape to cover the open area where the window glass was missing.
Plan of Correction:	The broken window was replaced 12/19/2023. Residents will be assessed for appropriate memory care placement. Staff will receive training regarding de-escalation and redirection of memory care residents. All memory care windows will be checked for safety and security, monthly Executive Director, Resident Services Director and Maintenance Director 1/31/2024
Standard #:	22VAC40-73-320-A
Description:	Based on the record review and staff interview the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility. Evidence: 1. The record for resident #2, admission date 11/21/23, did not contain a physical examination. 2. Staff #2 acknowledged the facility did not have a record of the resident?s physical examination.
Plan of Correction:	The physical exam was present in resident's chart. Resident services director and/or designee will continue to monitor all resident exams and pertinent paperwork for completion prior to resident's admission. Resident services director and/or designee will continue to monitor all resident exams and paperwork for completion prior to resident's admission. Executive Director will check resident charts for completion and accuracy monthly. Executive Director and Resident Services Director 12/08/2023
Standard #:	22VAC40-73-460-D
Description:	Based on the record review and staff interview the facility failed to ensure the facility shall provide supervision of resident schedules, care, and activities to include attention to specialized needs, such as wandering from the premises. Evidence: 1. During an interview with staff #1, staff #1 stated during morning rounds on 11/22/23 at 7:30 am, resident #2 was not located in the safe secure unit. During an interview with staff #3, staff #3 discovered a broken window located in an unoccupied room and based on the facility?s internal investigation it was determined resident #2 exited the safe secure unit through the window. 2. Resident?s #2 incident report dated 11/28/23 documents ?resident #2 was last seen by facility staff on 11/22/23 at 5:30 a.m. Resident #2 was located by staff #5 and Staff #6 around 1:00 p.m.? 3. During an interview with staff #5, and staff #6, staff #5 and staff #6 stated they located resident #2 off the premises of the facility on 11/22/23 in the city of Chesapeake. Staff #5 stated resident #2 was located in the afternoon around ?lunchtime.? 4. Resident?s #2 Assessment for Serious Cognitive Impairment dated 09/22/23 documents a diagnosis of Dementia.
Plan of Correction:	Resident was discharged from facility 11/23/2023. Staff received in service and education regarding memory care residents and safety. Executive Director, Resident services director and/or designee will assess and/or monitor resident behaviors to ensure resident safety and appropriateness. Service plans will be updated as needed and upon significant change. Executive Director, Resident Services Director and/or Resident services coordinator 1/31/2024
Standard #:	22VAC40-73-930-D
Description:	Based on the record review the facility failed to ensure for each resident with an inability to use the signaling device the following shall be met: once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum direct care staff shall make rounds no less than every two hours; the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. The documentation shall be retained at the facility for two years. Evidence: 1. Resident?s #1 Individualized Service Plan (ISP) dated 06/25/23 includes the ?resident will be checked on every 2 hours. Resident is unable to acclimate to use of call bell.? Resident?s #1 record did not include documentation rounds were made for Nov. 2023 and Dec. 2023.
Plan of Correction:	All clinical staff will receive education/in service regarding 2 hour checks 2 hour check forms will be completed and turned in at the end of each shift. Resident services coordinator and/or designee will ensure 2 hour check forms are submitted. Resident services director will review forms for completion Executive Director and Resident Services Director or Resident Services Coordinator 1/31/2024