VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Virginia Home for Adults
2701 Border Road
Chesapeake, VA 23325
(757) 545-6219

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: May 2, 2022 , May 3, 2022 , May 16, 2022 and May 17, 2022

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 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

An unannounced on-site renewal inspection was conducted on 5-2-22 (ar 07:30 a.m./dep 5:30 p.m). The facility census was 50. A tour of the facility was conducted, medication pass observation conducted, resident interviews and records reviewed/staff records and interviews conducted, emergency supplies reviewed and lunch meal observed. A preliminary exit meeting was conducted with the Administrator and documents requested on 5-2-22 and rec 5-3-22. An exit was conducted on 5-16-22 with the administrator, document requested received on 5-17-22. The Acknowledgement of Inspection form was sent via email to the Administrator on 5-3-22 and 5-17-22. 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 #:	22VAC40-73-40-B-8
Description:	Based on observation and staff interviewed, the facility failed to ensure the current license was posted in a place conspicuous to the residents and the public. Evidence: 1. On 5-2-22 during a tour of the facility with staff #1, the facility?s license was not posted. 2. Staff #1 acknowledged the license was not posted.
Plan of Correction:	The Administrator stated during the interview that maintenance painted the hall, and the posted License was on the board that was moved to paint. The board was seen in the front office with the license intact and put back in place at the time it was discover on same day. Maintenance has been informed of the standard and instructed that any time posting, or signs are moved to let a manager know so they can be placed up in another area until the work is finished. 5- 3-22 completed
Standard #:	22VAC40-73-260-C
Description:	Based on observation and staff interviewed, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR, in conformance with 22VAC40-73-260- A and B of the regulation, was posted in the facility so that the information was readily available to all staff at all times. The listing must indicate by staff person whether the certification is in first aid or CPR or both and must be kept up to date. Evidence: 1. On 5-2-22 following the medication administration pass, staff #2 was asked where the first aid and CPR listing was posted. 2. After searching the medication room and nursing station, staff #2 acknowledged the first aid and CPR listing was not posted in the facility.
Plan of Correction:	The Staff list with CPR and FIRST AIDE has been placed upon the wall in the front medication room and a copy of this list will remain in there upon now understanding this is required. Current Staff with CPR and First Aide is kept in the back office where scheduling is done. All direct Care Staff have both. 5-3-22 completed
Standard #:	22VAC40-73-300-B
Description:	Based on staff interviewed, the facility failed to ensure a written method of communication was utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. Evidence: 1. On 5-2-22, during the medication pass with staff #2, staff was asked to check the communication log to determine if resident #5?s medication was ordered or refill called in to the pharmacy as there was no medication for the 5-2-22 scheduled 11:00 am dosage. Staff stated the communication among staff was shared verbally and there was a board with information noted but was changed daily. 2. Staff was asked if the information was documented in the resident?s record if not in the communication log book. Staff was not sure if information was documented in the residents? record so that other staff members with the need to know was informed. 3. Staff #1 and #2 acknowledged the facility did not have a communication log of written communication.
Plan of Correction:	Administrator has purchased separate notebooks and they have been put in the front office identified as ?Shift Log? for each shift to communicate any needed information to the next staff to go along with our verbal shift report done daily. What was stated during the interview was Progress notes are kept in electronic form. The notes are made in the computer on each resident separately as well as a communication board daily and staff group text messages. 5-4-22 Completed
Standard #:	22VAC40-73-380-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s personal and social data document was kept current for residents. Evidence: 1. On 5-2-22, resident #3?s physical examination dated 3-20-21 documented resident allergic to Lipitor and Aspirin. 2. Resident #5?s physical examination dated 9-8-21 documented resident allergic to Sulfa drugs, Opiates, Bactrim and Gabapentin. 3. Staff #1 acknowledged the aforementioned residents? allergies not listed on social data form.
Plan of Correction:	Administrator and office manager will ensure all allergies are added to everyone?s Social Data Sheet. Every file will be rechecked. Going forward the Administrator will double check the HX and any information that comes in to make sure medication allergies are added to the Social Data. Date to be corrected: 6-10-22
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs. Evidence: 1. Resident #2?s uniformed assessment instrument (UAI) dated 2-8-22 documented stairclimbing need as not performed. The resident?s individualized service plan (ISP) dated 2-10-22 did not included this assessed need. 2. Resident #3?s social data documented resident hay fever allergy. The physical examination dated 3-30-21 documented allergy to Lipitor and Aspirin. The ISP dated 4-8-22 did not include these assessed needs. 3. Resident #5?s physical examination dated 9-8-21 documented resident allergic to Sulfa drugs, Opiates, Bactrim and Gabapentin. The UAI dated 10/3/21 documented bathing and dressing need assessed as human/help supervision. The ISP dated 10-4-21 did not included these assessed needs. 4. Resident #6?s discharge document from a local hospital dated 7-29-2015 and facility face sheet documented resident allergy to Haloperidol and Procycline. The ISP dated 3-1-22 did not included these assessed needs. 5. Resident #7?s physical examination dated 10-6-21 documented resident allergy to Aspirin. The ISP dated 10-6-21 did not include this assessed need. 6. Staff #1 acknowledged the aforementioned resident?s assessed needs were not documented on the residents? ISP.
Plan of Correction:	Each file will be reviewed and updated by the administrator and office manager. Going forward all needs assessed, and all medication allergies found on the resident?s physical or hx will be also noted on the ISP for each resident. The Administrator will double check these at the time of the final Care Plan review. Administrator did state the Stair climbing need noted on the UAI will be added to the ISP. As discussed during the interview, the city assessor marks ?stair climbing? as we do not have steps at our facility ?is not performed? in that aspect, the administrator will discuss with the city assessor the interpretation of this need seems to be different. Date Completed 6-7-22
Standard #:	22VAC40-73-550-F
Description:	Based on observation and staff interviewed, the facility failed to ensure the rights and responsibilities of residents was printed in at least 14-point type and posted conspicuously in a public place all the facility. Evidence: 1. On 5-2-22 during a tour of the facility staff #1 was asked where the residents? rights were posted. Staff stated at the front of the facility. The residents? rights and responsibility could not be located on the morning of 5-2-22. 2. Staff #1 acknowledged the residents? rights and responsibilities was not posted on the day the inspector?s tour of the facility.
Plan of Correction:	A Copy of the Residents Rights has now been placed in a binder upfront to reduce the risk of someone removing it, tearing it, or writing on them. Administrator has made staff aware of this requirement and will have a staff check daily to ensure it stays in place and available to residents and the public. Date Corrected:5-4-22
Standard #:	22VAC40-73-640-A
Description:	Based on record review, observation and staff interviewed, the facility failed to follow its medication management policy to ensure that a resident?s medication was ordered, filled or refilled for the resident in a timely manner to avoid missed dosage. Evidence: 1. On 5-2-22 during medication pass with staff #2, resident #5?s 11:00 AM Seroquel was not available to administer to the resident. 2. Staff #2 acknowledged the aforementioned resident?s medication was not available in the facility to administer at the dosing scheduled time.
Plan of Correction:	Medication manager will continue to check in all cycle meds in advance before the date of administering them and have a second staff check also to reduce the risk of missing a medication that may not have arrived with the cycle. The Administrator or manager will also check off on the cycle to ensure all meds are in the facility. Acknowledged during the interview, this medication did arrive at around 12:30pm on the same day and observed. Date Corrected 5-3-22
Standard #:	22VAC40-73-860-G
Description:	Based on observation and staff interviewed, the facility failed to ensure hot water at taps available to residents was maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F. Evidence: 1. On 5-2-22 during a tour of the facility with staff #5, the water temperature for the bathroom located across from room B-27 on the women?s hallway was 90 degrees F (10:31 a.m.). The shower across from room #15 and next to room #15 was 97.3 degrees (10:35 a.m.). 2. Staff #5 acknowledged the water temperature did not meet regulation requirement.
Plan of Correction:	Maintenance has adjusted the hot water heaters on the women?s hall to ensure the temperature reaches the 105-120 range. This was corrected during the visit. The administrator has advised maintenance to check these temperatures on a routine basis to be sure they stay in range daily and manager will do a temperature check weekly also and note it on the office calendar when done. Date Completed 5-3-22
Standard #:	22VAC40-73-870-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair and kept clean. Evidence: 1. On 5-2-22 during a tour of the facility with staff #1, the restroom located across from room #12, the ceiling was observed to be covered with gray colored substance. The hallway near the dining area was observed to have stacks of tiles and a machine of some with wheels located near the bookshelf with the clock and temperature reading. The air duct on the same hallway was missing a covering, exposing a brown colored substance and hanging electrical wiring. The call bells in the bathroom was not available and/or not operational on the hallway with the dining room and included men and women (shared bedrooms). 2. Staff #1 acknowledged the building condition. Staff #6 acknowledged the call bells not working in the bathrooms on the day of the inspection.
Plan of Correction:	New Call Bells are in place and being monitored by management staff. Housekeeping has been informed and additional training giving by administrator on High Dusting the ceilings, lights, and pipes in the bathrooms. Maintenance was also met with by administrator to discuss removing any tiles from the hallway that are not being used at that time. As noted on the day of the inspection a brand-new AC unit was being installed in the hallway, this was where it is noted that wires were hanging from the ceiling. This work was completed the same day and no wires are hanging. It was acknowledged that Maintenance was also observed as putting in New Call Bells in each bathroom on day of inspection. Date Completed: 5-4-22
Standard #:	22VAC40-73-870-E
Description:	Based on observation and staff interviewed, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, was kept clean and in good repair and condition. Evidence: 1. On 5-2-22 during a tour of the facility with staff #1, the tile in the bathroom on the male hallway was cracked. The water lines underneath the bathroom sinks are rusted and covered with a grey colored substance. The covering over the plumbing wire along the walls and near the sinks are cracking and peeling away 2. The ladies bathroom across from room #12, wall above face sink needs painting. The vents in the ceiling in the unisex restroom across from room #10, the ceiling vents covered with a grey colored substance, also the electrical tubing in the hallway in front of the bathroom door covered with grey colored substance. The walls in bathrooms on the male and female hallways in need of cleaning and or painting. 3. Staff #1 acknowledged areas of the facility needed cleaning and/or repairing.
Plan of Correction:	Housekeeping has gone back through with Administrator and been informed of the expectation of thoroughly cleaning walls in the bathrooms as well as High Dusting. A manager will check them daily. Maintenance has been scheduled to paint the bathrooms that need it as well as replace the rusted pipe under the one sink as observed. Maintenance has replaced the crack tile in the men?s bathroom. Going forward maintenance will do a weekly report for Administration of any work done as well as inspection done on bathroom floors, walls, and equipment to ensure all bathrooms are kept and maintained in good repair. Date to be Corrected 6-10-22
Standard #:	22VAC40-73-960-B
Description:	Based on observation and staff interviewed, the facility failed to ensure the fire and emergency evacuation drawing posted included all of the requirements of the regulations. Evidence: 1. On 5-2-22 during a tour of the facility with staff #1, the fire and emergency evacuation drawing did not include the primary and secondary route and the location of telephones in the building. 2. Staff #1 acknowledged the evacuation posting did not include all required information.
Plan of Correction:	Administrator has added a symbol for telephone locations and secondary route to all the drawings for fire and evacuation located on each hall. Date Corrected 5-5-22
Standard #:	22VAC40-73-960-C
Description:	Based on observation and staff interviewed, the facility failed to ensure the telephone numbers for the fire department, rescue squad or ambulance, police, and Poison Control Center was posted by each telephone. Evidence: 1. On 5-2-22 staff #2 was asked where the emergency numbers were posted as the inspector did not see the posting. Staff #2 looked in the medication room and also the nursing station and the listing was not found. 2. Staff #1 and #2 acknowledged the emergency telephone numbers required were not posted on the day of the inspection.
Plan of Correction:	All emergency numbers are now posted at each phone station. These will be put in plastic and stuck to the location to reduce the risk of a staff or resident removing them from the required phone location. Date Corrected: 5-5-22