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: Nov. 2, 2023

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 11/02/2023 from 8:35 am to 12:40 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: 9 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed. 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 checked in two of the resident bathrooms. 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 #:	22VAC40-73-310-H
Description:	Based on the record review the facility failed to ensure in accordance with 63.2-1805 D of the Code of Virginia, assisted living facilities shall not admit or retain individuals with any of the following conditions or care needs: psychotropic medications without appropriate diagnosis and treatment plans. Evidence: 1. The record for resident #1, admitted 12/25/22, contains a physician order dated 11/23/22 and a physical exam dated 12/23/22 prescribing the following medication: Bupropion ER 150mg, to give every 12 hours for depression. Resident?s #1 record did not contain a treatment plan dated prior to or on admission for the psychotropic medication, Bupropion.
Plan of Correction:	Staff will ensure that any resident's use of psychotropic medication is included within their treatment plan prior to admission to Pritchard Road Assisted Living.
Standard #:	22VAC40-73-450-C
Description:	Based on the record review the facility failed to ensure the comprehensive individualized service plans (ISP) shall include the following: a description of identified needs based upon the uniform assessment instrument (U\AI), and other sources. Evidence: 1. Resident?s #1 UAI dated 03/10/23 documents the resident?s behavior pattern as ?wandering/passive weekly or more.? Resident?s #1 heath care oversight dated 05/19/23 includes recommendations for the facility to address on the ISP, the resident?s behavior pattern of wandering. Resident?s #1 ISP dated 03/13/23 does not include or address the resident?s behavior pattern of wandering/passive as documented on the resident?s UAI and health care oversight.
Plan of Correction:	Staff will make corrections to ISP to ensure that it includes a description of identified needs.
Standard #:	22VAC40-73-960-B
Description:	Based on observation the facility failed to ensure a fire and emergency evacuation drawing shall show primary and secondary escape routes, areas of refuge, and assembly areas. Evidence: 1. During a tour of the facility with staff #2 the fire and emergency evacuation drawings posted in the facility did not show primary and secondary escape routes, areas of refuge, and assembly areas.
Plan of Correction:	Staff will include a place of gathering, as well as primary and secondary escape routes on emergency evacuation drawing.
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 shall be posted by each telephone shown on the fire and emergency evacuation plan. Evidence: 1. During a tour of the facility with staff #2, a listing of the telephone numbers for the fire department, rescue squad or ambulance, police, and poison control was not posted near the telephone shown on the facility?s fire and emergency evacuation plan. 2. Staff #2 confirmed the telephone numbers for the fire department, rescue squad or ambulance, police, and poison control was not posted near the telephones in the facility.
Plan of Correction:	Staff will post telephone numbers for fire department,rescue squad, ambulance, police, and poison control center by each telephone andon emergency evacuation drawing.