VIRGINIA DEPARTMENT OF SOCIAL SERVICES

LAV'M Adult Residence
912 S. Battlefield Blvd.
Chesapeake, VA 23322
(757) 546-2810

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: March 28, 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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Comments:

Type of inspection: Renewal An unannounced renewal inspection took place on 03/28/2024 at 08:32 am until 03:45 pm. 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: 21 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for four residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on the onsite record review, and staff interview, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. The record for resident #7, discharge date 12/25/2023, contains the following: a progress note dated 12/25/23 that documents a medical emergency for the resident to include a call to 911; a discharge statement for the resident?s death that occurred on 12/25/23. No incident report of the resident?s medical emergency and death was provided to the Licensing Inspector. 2. The facility?s emergency plan includes to report medical emergencies to ?DSS Licensing office the next day.? Staff #5 was unable to provide evidence of reporting to DSS, resident?s #7 medical emergency and death.
Plan of Correction:	The Licensee and the Administrator assure that follow up phone calls and other communication methods be done to ensure receipt of Incident Reports, Discharge Summary Reports, and other important documents
Standard #:	22VAC40-73-560-E
Description:	Based on observation and interview, it was determined that the facility failed to ensure that all resident records shall be kept in a locked area, except that information shall be made available as noted in subsection F of this section. Evidence: 1. The following binders were observed and reviewed in the common area of the facility: Medication Pharmacy Review Binder, Home Health Notes, Incident Report logs, List posted with residents? names, social security number and date of birth posted. 2. Staff #5 was present and confirmed that the binders should be stored in locked area.
Plan of Correction:	The Licensee and the Administrator assure that binders with confidential resident and employee information will not be placed in the Facility?s common area but in a secured and locked place, moving forward.
Standard #:	22VAC40-73-560-F
Description:	Based on observation and interview, it was determined that the facility did not ensure that all records are treated confidentially, and that information shall be made available only when needed for care of the resident. Evidence: 1. The following binders, which contained confidential information, were observed, and reviewed in the common area of the facility: Medication Pharmacy Review Binder, Home Health Notes, Incident Report logs, List posted with residents? names, social security number and date of birth posted. 2. Staff #5 was present and confirmed that the binders contained confidential information.
Plan of Correction:	The Licensee and the Administrator assure that all Resident records are treated confidential and be locked in a secured place and be made available only when needed for the care of Residents
Standard #:	22VAC40-73-660-A
Description:	Based on observation, it was determined that the facility did not ensure that medications shall be stored in a manner consistent with current standards of practice and the storage area shall be locked and the individual responsible for medication administration shall keep the keys to the storage area on his person. Evidence: 1. During the medication pass observation with staff #3, Staff #3 left the medication cart unlocked in the common area while administering medications to resident #9 in the resident?s room. 2. Staff # 3 was assigned to the medication cart, and the key to the medication cart was observed to be inserted into the lock/unlock device on the medication cart.
Plan of Correction:	The Licensee and the Administrator assure that review of Standards of Practice for medication pass be always observed and practiced. Training and refresher courses on Medication Administration are made available to Staff #3 and other Facility RMAs.