VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Pritchard Road Assisted Living
206 Pritchard Road
Virginia beach, VA 23452
(757) 340-8509

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Oct. 11, 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 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 ARTICLE 1 ? SUBJECTIVITY 22VAC40-80 THE LICENSE

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: An unannounced renewal inspection took place on 10/11/22 from 8:45 am to 3:22 pm. The Acknowledgement of Inspection form was signed and left at the facility. Number of residents present at the facility at the beginning of the inspection: 10 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: 2 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Lunch and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication plan, medication carts for assisted living, fire inspection report, health inspection report, and a staffing schedule. Water temperature was checked in two of the resident bathrooms. Additional Comments/Discussion: The facility is currently staffed with two employees. 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 #:	22VAC40-73-210-A
Description:	Based on the onsite record review and staff interview the facility failed to ensure in a facility licensed only for residential living care, all direct care staff shall attend at least 14 hours of training annually.(Exception: Direct care staff who are licensed health care professions or certified nurse aides shall attend at least 12 hours of annual training). Evidence: 1. The record for Staff #2, a certified nurse aide hired 01/01/12 did not include documentation of 12 hours of annual training. The last date of training documented in the record for staff #2 is 09/29/21. 2. Staff #2 acknowledged there is no record of documentation that she received 12 hours of training annually.
Plan of Correction:	Staff will ensure/obtain the proper documentation/certificates for 14 hours of annual training.
Standard #:	22VAC40-73-210-F
Description:	Based on staff record review the facility failed to ensure when adults with mental impairments reside in the facility, at least four of the training hours required annually focus on topics related to residents? mental impairments. Evidence: 1. The record for Staff #1(hired 01/01/12) and Staff #2 (hired 01/01/12) did not document 4 hours of annual training in mental impairments. 2. The record for resident #1 documents a mental impairment of schizoaffective and bipolar disorder. 3. The record for resident # 3 documents a mental impairment of schizoaffective disorder. 4. Staff # 1 and staff #2 acknowledged there is no evidence they received 4 hours of annual training in mental impairments.
Plan of Correction:	Staff will ensure/obtain the proper documentation/certificates to show completion of 4 hours of mental health training.
Standard #:	22VAC40-73-320-B
Description:	Based on record review the facility failed to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident. Evidence: 1. In the record of resident #2, the most recent TB risk assessment is dated 09/09/21.
Plan of Correction:	Staff will ensure that all residents have an up to date, annual TB risk assessment on file.
Standard #:	22VAC40-73-430-H-1
Description:	Based on record review the facility failed to ensure at the time of discharge, the assisted living facility shall provide to the resident, and as appropriate, his legal guardian and designated contact person a dated statement signed by the licensee or administrator that contains the actions taken by the facility to assist the resident in discharge and relocation process. Evidence: 1. Resident #8 discharge statement dated 09/23/22 did not include documentation of the actions taken by the facility to assist the resident in discharge and relocation process.
Plan of Correction:	Staff will include the actions taken and assistance given to resident during the discharge relocation process to the resident?s discharge statement.
Standard #:	22VAC40-73-450-F
Description:	Based on record review the facility failed to ensure individualized service plans (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. Resident # 2 record documents a hospital admission on 07/24/22 due to a 2nd degree burn to lower limb. 2. Resident #2 Uniform Assessment Instrument (UAI) dated 08/22/22 documents a need for Dressing/Wound Care for Lower limbs Weekly. 3. Staff # 2 acknowledged the resident receives wound care services with Chesapeake Regional Wound Care. 4. Resident # 2 record documents an ISP dated 11/23/21. The ISP dated 11/23/21 was not updated to include the change in resident?s condition due to the 2nd degree burn to lower limb and a need for Dressing/Wound Care.
Plan of Correction:	Staff will ensure to review and update resident?s ISPs once a year and as needed.
Standard #:	22VAC40-73-640-A
Description:	Based on the medication pass observation the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated medications. Evidence: 1. LI observed the following expired medications on a medication cart at the facility: Reguloid Capsule and MAPAP PM expired 07/03/2022 for resident # 4.
Plan of Correction:	Staff will include the methods and protocols used regarding outdated medications in the facility?s medication management plan
Standard #:	22VAC40-73-700-2
Description:	Based on observation during an onsite tour of the facility the facility failed to post ?No Smoking-Oxygen In Use? signs in any room of a building where oxygen is in use. Evidence: 1. Resident # 5 room contained an oxygen tank. 2. Staff #2 acknowledged resident #5 is prescribed the use of oxygen. 3. Staff # 2 acknowledged the oxygen in use sign was not placed in the room of resident #5 during the tour of the facility.
Plan of Correction:	Staff will ensure to post ?No Smoking-Oxygen In Use? signs at all times.