VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harbor's Edge
One Colley Avenue
Norfolk, VA 23510
(757) 616-7938

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: July 22, 2024 and July 24, 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 22VAC40-73 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

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/22/2024 from 8:45 am to 4:45 pm and 07/24/2024 from 12:45 pm to 2:55 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: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast and an activity were observed. A medication pass observation was completed for 3 residents. The following were reviewed: resident and staff records, emergency preparedness drills, and medication carts. Water temperature was measured, and the call bell system was monitored. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on record review, the facility failed to ensure prior to admission to a safe, secure environment, residents are assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. The serious cognitive assessments for Resident #3 (dated 05/13/2024) and Resident #5 (dated 11/13/2023) indicate the resident is able to recognize danger or protect their own safety and welfare and the residents reside in a safe, secure environment.
Plan of Correction:	A 100% audit was completed on all serious cognitive assessments to ensure the documentation was correctly completed. The Medical Director was notified of the deficient documentation from the inspection. The serious cognitive assessments for Resident #3 and Resident #5 will be corrected to reflect that the residents are unable to recognize danger or protect their own safety and welfare. All serious cognitive assessment forms will be checked by the Administrator, or designee upon admission to ensure they are completed correctly prior to being scanned into the resident?s EMR.
Standard #:	22VAC40-73-1140-B
Description:	Based on record review, the facility failed to ensure within four months of the starting date of employment in the safe, secure environment, direct care staff attend at least 10 hours of training in cognitive impairment that meets the requirements of subsection C of this section. Evidence: 1. Staff #1 (hired 12/05/2023) did not have at least 10 hours of training in cognitive impairment within four months of their hire date.
Plan of Correction:	A review of all Relias courses assigned to assisted living staff will be completed to ensure there are sufficient hours of cognitive training assigned and completed per standard.
Standard #:	22VAC40-73-250-C
Description:	Based on record review, the facility failed to maintain personal and social data on staff to include verification that the staff person has received a copy of their current job description. Evidence: 1. Staff #1 and Staff #2?s record does not include verification that the staff person has received a copy of their current job description.
Plan of Correction:	Staff #1 and Staff #2 will be instructed to go into Paylocity and sign the job descriptions that were sent to them by Human Resources. An audit will be completed on all new staff hired within the last six months to ensure a signed job description is signed in the system.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #1 (hire date 12/05/2023) works as direct care staff and does not have documentation of a current certification in first aid in their staff record.
Plan of Correction:	Staff #1 will be scheduled for the next first aid class in the onsite clinic to bring them into compliance with this standard. A 100% audit of all new hires assigned to assisted living that provide direct care will be completed to ensure all follow this regulation. Any staff out of compliance will be scheduled and complete a first aid course within 30 days.
Standard #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure the individualized service plan be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative when reviews and updates of the plan have been made. Evidence: 1. The ISPs for Resident #4 (dated 03/13/2024), Resident #5 (dated 03/07/2024), and Resident #7 (dated 09/30/2023) were not signed and dated by the resident or his legal representative.
Plan of Correction:	ISPs for Resident #4, Resident #5, and Resident #7 were corrected. ISPs were signed by their responsible parties prior to the submission of this plan of correction.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to review and update individualized service plans as needed for a significant change of a resident?s condition. Evidence: 1. Resident #5 admitted to the safe, secure environment on 11/16/2023; however, Resident #5?s ISP was not reviewed and updated to reflect this significant change.
Plan of Correction:	Corrected ? Resident #5 ISP updated with significant change of condition as of 8/1/2024.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication. Evidence: 1. The following expired medications were observed in the medication carts at the facility: Senexon 8.6 mg-50 mg tablets expired 07/17/2024 and Prochlorperazine 10 mg tablets expired 07/20/2024 for Resident #5 and Calcium Citrate 630 mg tablets expired 07/2022 for Resident #10.
Plan of Correction:	All identified medications were immediately removed from the carts during the inspection and will be audited weekly ? This will be ongoing.
Standard #:	22VAC40-73-680-D
Description:	Based on observation, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. During a medication observation with Staff #4 on 07/22/2024, a Reduced Sugar Mighty Shake was not available for administration to Resident #7. 2. During a medication observation with Staff #2 on 07/22/2024, it was documented Resident #2?s Prilosec 20 mg tablet was not administered at 7 am.
Plan of Correction:	The Dietary Manager notified, and the appropriate Mighty Shake was made available to the staff for the resident?s med pass. The Dietary Manager will make weekly rounds to ensure that the resident has the correct supplement available. It was identified during the inspection that the Prilosec order for Resident #2 was discontinued in error which resulted in the missed dose. The order was corrected by the end of the inspection.
Standard #:	22VAC40-73-930-D
Description:	Based on interview, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility. Evidence: 1. Staff were unable to provide documentation of rounds no less often than every two hours for each resident with an inability to use the signaling device within the safe, secure environment.
Plan of Correction:	Staff will now document rounds in the POC charting in MatrixCare. Assistant Administrator updated the CNA charting to include documentation on their rounding. Education was provided on the expectation and importance of completing these rounds.
Standard #:	22VAC40-73-970-A
Description:	Based on interview, the facility failed to ensure fire and emergency evacuation drill frequency and participation be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month. Evidence: 1. From 7/2023 to 7/2024, documentation provided by Staff #5 shows fire drills were conducted on 4 occasions within the assisted living: 12/29/2023, 02/22/2024, 03/14/2024, and 04/05/2024.
Plan of Correction:	It was identified that the facility was deficient in the amount of fire drills for the year. Education was provided to the Director of Life Safety and Security on this standard during the inspection. The schedule for fire drills has been updated to reflect the appropriate shifts and unit to receive credit for compliance. Staff education will be ongoing.