MADONNA HOME INC.
814 W. 37th Street
Norfolk, VA 23508
(757) 623-6662
Current Inspector: Lanesha Allen (757) 715-1499
Inspection Date: Aug. 8, 2022
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 BUILDINGS AND GROUND
22VAC40-73 EMERGENCY PREPAREDNESS
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
63.2 GENERAL PROVISIONS
63.2 LICENSURE AND REGISTRATION PROCEDURES
63.2 FACILITIES AND PROGRAMS
22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES
22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
22VAC40-80 THE LICENSE
22VAC40-80 THE LICENSING PROCESS
- Comments:
-
An unannounced renewal inspection was initiated and completed on 08/08/22- from 8:30 a.m. until 1:50 p.m. The Acknowledgement of Inspection form was signed and left at the facility for this date of the inspection.
- Violations:
-
Standard #: 22VAC40-73-160-A Description: Based on observation and staff interview , the facility failed to ensure that the administrator completed 20 hours of annual training.
Evidence:
Staff # 2 training record contained documentation of 11.25 hours of annual training.Plan of Correction: Staff # 2 will register for in service to complete 8.75 hrs.
Standard #: 22VAC40-73-250-D Description: Based upon staff record review and discussion, the facility failed to ensure that each staff person be evaluated annually and submit the results of a risk assessment, documenting that the individual is free of tuberculosis.
Evidence: Staff #1 most recent tuberculosis is dated for 2-1-19.Plan of Correction: Annual health evaluations will be posted annually and staff will be reminded one month prior to annual date.
Standard #: 22VAC40-73-290-A Description: Based on observation and discussion, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a place in the facility.
Evidence:
1. During Inspection on 08/08/2022, Staff # 1 and Staff # 2 acknowledged the on-site person in charge was not posted.Plan of Correction: Staff on duty will be posted before report is given
Standard #: 22VAC40-73-550-G Description: Based on observation and record review, the facility failed to provide evidence of the rights and responsibilities review by resident annually.
Evidence:
The resident rights review dated for 1/30/22 for resident #5 was not signed.Plan of Correction: All forms will be double checked for appropriate signatures.
Standard #: 22VAC40-73-750-E Description: Based on observation and discussion, during tour of the facility, the facility failed to ensure that residents always have cleaned sheets and pillowcases.
Evidence:
During the tour of the physical plant, LI and LA
observed a pile of broken tree branches and a
flat screen television located on the ground in the
backyard of the facility.Plan of Correction: Each room will be checked on each shift for soiled sheets or pillow cases. Corrections will be made immediately.
Standard #: 22VAC40-73-860-I Description: Based on observation and discussion, the facility failed to store cleaning supplies and other hazardous materials in a looked area.
Evidence:
On August 8, 2022, during the tour of the facility, bleach and laundry detergent were found in the laundry room unlocked on the first floor.Plan of Correction: All Hazardous materials will be kept in lock areas . The housekeeper will remove the amount from the containers as needed.
Standard #: 22VAC40-73-870-A Description: Based on the onsite observation and discussion, the facility failed to ensure that the interior and exterior of all buildings shall be kept clean and free of rubbish.
Evidence:
During the tour of the physical plant , LI and LA observed a pile of broken free branches and a flat screen television located on the ground in the backyard of the facility.Plan of Correction: Tree branches will be cut the day before rubbish.
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.