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757 Cedar Road
CHESAPEAKE, VA 23322
(757) 263-0011
| Inspection Dates: | 10/31/2024 |
|---|---|
| Complaint Related: | NO |
| Inspector: | Donesia Peoples: 757 353-0430 |
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: 10/31/2024 from 10:35 am to 12:45 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Three self-reported incidents were received by VDSS Division of Licensing on 10/10/2024, 10/18/2024, and 10/21/2024 regarding allegations in the area(s) of: Admission, Retention, and Discharge of Residents, Resident Care and Related Services, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: 96 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: Resident Services and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. A violation notice was issued; any violation(s) not related to the self-reports 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Description: Based on record review, 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. Evidence: 1. On 10/09/2024, Resident #1 exited the safe, secure environment. 2. An observation noted in Resident #1’s record by Staff #3 indicates both Staff #3 and the receptionist “did not hear or see the alarm going off” and that the alarm did not “alert to the tablets.”
Testing for each emergency exit will be completed by Maintenance Director and documented in TELS. Record logs will include a list of emergency door locations. Staff will be educated on elopement procedure. Monthly testing will be completed by the 15th of each month beginning November 15,2024. Compliance will be met by November 31st and continued monitoring by Administrator and/or Designee.
Description: Based on discussion, the facility failed to ensure the UAI for residents be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition. Evidence: 1. Staff #2 was unable to provide a current UAI for Resident #1 and Resident #4.
An audit of all resident charts will begin on 11/1/2024 for UAI compliance. Following audit of all charts, random selection of charts will be audited for UAI compliance weekly for 4 weeks and quarterly thereafter for the 1st and 2nd quarter of 2025. Compliance will be monitored by Health Services Director and/or Designee.
Description: Based on record review and discussion, the facility failed to assume general responsibility for the health, safety, and well-being of the residents. Evidence: 1. On 10/18/2024, Resident #2 and Resident #3 were found on the floor after an apparent altercation. 2. Resident #2 sustained a major injury to their right shin.
Rounding will be completed by staff at minimum of every two hours during sleeping hours. Unit will be appropriately staffed according to the census. Compliance is completed and will be monitored by Memory care manager and/ or Designee.
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