VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Indian River Assisted Living
1012 Justis Street
Chesapeake, VA 23325
(757) 523-4659

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Jan. 11, 2024 and Jan. 12, 2024

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

Technical Assistance:

22VAC40-73-50 22VAC40-73-490

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: 1/11/2024 from 8:35 am to 3:00 pm and 1/12/2024 from 5:55 am to 8:20 am. 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: 85 Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 5 residents. The following were reviewed: resident and staff records, medication carts, and water temperatures. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1070-B
Description:	Based upon observation, the facility failed to ensure that ordinary materials or objects that are harmful to resident be inaccessible to the residents except under staff supervision. Evidence: 1. During a tour of the facility on 1/11/2024, the facility?s maintenance closet adjacent to the dining room were left unlocked. Both rooms contained jars of paint, paint supplies, cleaning supplies, and various maintenance equipment.
Plan of Correction:	Maintenance Coordinator and Administrator will ensure that the Maintenance closet remains closed and checks will be documented in main log.
Standard #:	22VAC40-73-200-D
Description:	Based on record review and interview, the facility failed to obtain a copy of the certificate issued or other documentation indicating that the person has met one of the requirements of subsection C of this section, which shall be part of the staff member's record in accordance with 22VAC40-73-250. Evidence: 1. Staff #3 works at the facility as direct care staff; however, their record did not include a copy of the certificate issued or other documentation indicating that the person has met one of the requirements of subsection C of this section. 2. Staff #5 acknowledges the facility does not have a current certificate issued or other documentation indicating Staff #3 meets one of the requirements of direct care staff in their records.
Plan of Correction:	Staff #5's Training School was contacted, and her training was verified by the school and her training was dated. The school would not provide any certifications after-the-fact. All future hires must provide their certification(s) or will not be hired.
Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents submit the results of a risk assessment, documenting the absence 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. Evidence: 1. The TB risk assessment for Staff #2 (hired 11/21/2023) was not completed.
Plan of Correction:	All new hires will have a negative TB reading or TB screening before their first day of work.
Standard #:	22VAC40-73-550-F
Description:	Based on observation, the facility failed to post the rights and responsibilities of residents conspicuously in a public place. Evidence: 1. During the tour of the facility on 1/11/2024, only page 1 of the rights and responsibilities of residents was posted.
Plan of Correction:	The complete set of Resident Rights and Responsibilities will be posted by the DSS License and checked weekly to be in compliance.
Standard #:	22VAC40-73-550-G
Description:	Based on record review, the facility failed ensure the rights and responsibilities of residents in assisted living facilities be reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section. Evidence: 1. The following residents did not have current documentation of an annual review of resident rights and responsibilities: Resident #3, Resident #4, and Resident #5.
Plan of Correction:	The Activities Coordinator will review in January the Resident Rights and Responsibilities and follow-up with all Guardians and POAs.
Standard #:	22VAC40-73-610-B
Description:	Based on observation, the facility failed to ensure menus for meals for the current week are dated and posted in an area conspicuous to residents. Evidence: 1. The facility did not have menus for meals for the current week posted in an area conspicuous to residents.
Plan of Correction:	Indian River will post the weekly menu outside of the Dining Room.
Standard #:	22VAC40-73-640-A
Description:	Based on observation and interview, the facility failed to ensure their written plan for medication management includes methods to prevent the use of outdated medications and methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. Evidence: 1. The following expired medications were observed in the medication carts at the facility on 1/11/2024: PRN Q-Tussin expired 12/21/2023 for Resident #8, PRN Promethazine expired 10/25/2023 for Resident #12, PRN Acetaminophen 325 mg tablets expired 10/28/2023 for Resident #13, Allopurinol 100 mg tablets expired 3/3/2023 for Resident #14, Aspirin 81 mg tablets expired 8/2022 for Resident #15, Ammonium Lactate lotion expired 10/13/2023 for Resident #16, and Lidocaine Solution expired 9/29/2023 for Resident #17. 2. While ensuring accurate counts of all controlled substances with Staff #4 on 1/12/2024, it was discovered that the count indicated on the Controlled Drug Record was not consistent with the amount of medication for Resident #20?s Gabapentin 300 mg capsules with 141 noted on the record as available with 143 capsules on the medication cart and Resident #21?s Zolpidem Tartrate 5 mg tablets with 27 noted on the record as available with 26 tablets on the medication cart. 3. Staff #4 acknowledged the Controlled Drug Record was not consistent with the amount of the two medications identified on the medication cart.
Plan of Correction:	On a weekly basis, the RCC and ARCC will inspect all 4 medication carts for any expired medication and remove them from the cart. Per policy, the RMA must conduct a narcotic count at the end of their shift and count with a nursing team member to ensure the narcotic count is reconciled. On a weekly basis, the RCC or ARCC will conduct a 2 week inventory report.
Standard #:	22VAC40-73-870-A
Description:	Based upon observation, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. Evidence: 1. One of the east hall bathrooms has tiles missing. 2. The west hall bathroom has chipped tiles and paint peeling on the walls. 3. The wall corner guard of the wall between the south and west hall is unsecure to the wall. 4. The blinds and dresser in the room of Resident #8 were noted to be broken. 5. A cracked floor tile was noted in the room of Resident #18. 6. The emergency exit adjacent from Resident #19?s room was noted to have a blanket covering the bottom of the doorway and cracked floor tiles. 7. The beauty shop has a grey substance on vent in the ceiling.
Plan of Correction:	Building and Grounds to be checked weekly by Administrator and Maintenance Coordinator. Any concerns will be addressed, repaired, or replaced. Community will continue to hold our quarterly Safety Committee meetings with continued safety inspections.
Standard #:	22VAC40-73-980-C
Description:	Based on record review, the facility failed to ensure first aid kits be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence: 1. Staff #4 was unable to provide documentation of monthly checks on the first aid kit.
Plan of Correction:	A replacement First Aid Kit checkoff list was put in place and will be checked monthly by the RCC or ARCC. Any expired dates will be replaced.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. The following staff did not have a criminal history record report completed on or prior to the 30th day of employment: Staff #6 (hired 6/7/2023) completed 12/7/2023, Staff #7 (hired 6/13/2023) completed 12/8/2023, and Staff #8 (hired 11/1/2023) not completed at the time of inspection on 1/11/2024.
Plan of Correction:	The Administrator or BOM will conduct a criminal history record through the Virginia State Police for all new hires on their orientation day or prior.
Standard #:	22VAC40-90-40-H
Description:	Based on record review, the facility failed ensure any person employed does not have a conviction of any of the barrier crimes. Evidence: 1. Staff #9 was hired on 06/18/2022. A criminal history record report for Staff #9 was completed on 07/06/2022. The criminal history record report indicates Staff #9 was convicted of two misdemeanor barrier crimes in 1997.
Plan of Correction:	All criminal history record will be reviewed with the employee's application and Sworn Statement and to ensure compliance with the barrier crime listing. Staff #9 was terminated on 1/22/24.