VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Mennowood Retirement Community
13030 Warwick Blvd.
Newport news, VA 23602
(757) 249-0355

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: March 11, 2024 and March 12, 2024

Complaint Related: No

Areas Reviewed:

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 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Monitoring An unannounced on-site complaint inspection was conducted on 3-11-2024 by two inspectors from the Peninsula Licensing Office. (Ar 08:05 a.m./dep 16:45 p.m). The census was 69. Day two, one inspector (Ar 09:06 a.m./dep 12:25 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on observation and staff interviewed, the facility failed to ensure the blood glucose monitoring practices were consistent with CDC recommendations. Evidence: 1. On 3-11-24 during the medication pass observed in the safe, secure unit with staff #3, resident #9?s glucometer was observed to not have a label. 2. Staff #3 acknowledged the resident?s glucometer was not labeled.
Plan of Correction:	I. Corrective Action: Glucometer was labeled the day it was identified. II. How to Identify: Weekly cart audits to include verifying glucometer and storage container are both labeled with resident?s name. III. Systemic Changes: Director of nursing or designee will complete weekly audit. IV. Monitoring Process: Director of Nursing or designee will ensure completion of audits are done within 30 days of admission. V. Completion Date: April 31, 2024
Standard #:	22VAC40-73-450-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee, and by the resident or the legal representative. Evidence: 1. On 3-11-24, resident #1?s ISP dated 10-18-23 was not signed and dated by the resident or the legal representative. 2. Resident #2?s ISP dated 2-8-24 was not signed and dated by resident or the legal representative. 3. Staff #1 and #2 acknowledged, the residents? ISP was not signed and dated by the resident or legal representative.
Plan of Correction:	I. Corrective Action: Care plans will be signed at the time of care plan meeting or documentation of telephone or zoom meetings. If unable to obtain signature an email will be sent and/or documentation will be noted. II. How to Identify: Complete a chart audit to identify care plans with missing signatures and obtain signatures as warranted. III. Systemic Changes: Director of Nursing or designee will monitor and assure care plans have signatures upon completion of meeting with resident/family members. IV. Monitoring Process: The Ed and/or designee will ensure signatures are on care plans or documentation acquired. V. Completion Date: April 31, 2024