VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Gardens of Virginia Beach
5620 Wesleyan Drive
Virginia beach, VA 23455
(757) 499-4800

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Feb. 24, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced monitoring inspection was conducted by a Licensing Representative on February 24, 2020 from 8:47 a.m. to 11:17 a.m. regarding concerns for resident abuse. There were 100 residents in care. The Business Office Manager and Director of Resident Care were present throughout the inspection. The following topics were discussed: therapy services included on resident Individualized Service Plans (ISPs), staff training regarding transfers and resident rights, and restraint review. Please submit your ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it within 10 calendar days. The plan of correction must indicate how the violation will be or has been corrected. The plan of correction must include: 1. Step(s) to correct the noncompliance with the standard(s) 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative measures.

Violations:

Standard #:	22VAC40-73-1030-B
Description:	Based on record review and interview, the facility failed to ensure within four months of the starting date of employment, direct care attended six hours of training in working with individuals who have a cognitive impairment. Evidence: 1. Staff #1?s date of hire was 03-08-19 as a medication aide/resident assistant. 2. As of the date of inspection on 02-24-20, staff #1?s record did not contain any hours of training completed on working with individuals that have a cognitive impairment. 3. Staff #2 acknowledged that the facility has a mixed population, and that staff #1 had not completed the required training within four months of the starting date of employment.
Plan of Correction:	Direct Care Staff Cognitive Impairment Training The facility failed to ensure within four months to the starting date of employment, direct care staff attended six hours of training in working with individuals who have cognitive impairment. Steps to correct the noncompliance with the standard Staff #1 is no longer employed with The Gardens of Virginia Beach. ED/BOM will conduct an audit of all direct care staff for compliance with the required six hours of cognitive impairment training. ED/DRC/BTR Director will schedule all direct care staff in need of required cognitive impairment training to attend training in cognitive impairment presented by the BTR Director Measures to prevent the noncompliance from occurring again The facility will complete the required 6 hour cognitive impairment training with new employees during hiring orientation or with in the 4 month widow. The BOM will monitor new employee?s cognitive impairment training monthly for 3 months beginning 04/01/2020 and ending on 6/30/2020. Any staff identified as needing training will be provided with training.
Standard #:	22VAC40-73-280-A
Description:	Based on record review and interview, the facility failed to have staff adequate in knowledge and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans. Evidence: 1. On 02-21-20, an incident report was received following an initial incident report received 02-17-20 by the regional licensing office. The 02-21-20 report documented the following, ?Follow up report for alleged resident abuse. On February 16, 2020?. reported to [staff title, staff #3 name]? deemed as inappropriate care for [resident #1] that occurred on February 14th? identified [staff #1]? of being a little rough with transferring [resident #1] from [resident #1] wheelchair to [resident #1] bed? knows [resident #1] is a two person transfer and [staff #1] did the transfer by [staff #1] self?? 2. Upon interview with staff #1 on 02-24-20, staff #1 acknowledged resident #1 is a two-person transfer, and staff #1 transferred the resident without assistance stating, ?I didn?t know [resident #1] was a two-person transfer.? 3. Resident #1?s Individualized Service Plan (ISP) dated 01-23-20 documented, ?[Resident #1?s name] is unable to participate in the act of transferring. 2 staff members to provide full physical assistance to lift resident and transfer as needed.? 4. Staff #2 stated during interview on 02-24-20, ?We were short-staffed that day? as to why staff #1 did not have assistance with transferring resident #1. 5. Staff #2 acknowledged that staff #1 was not providing services as determined by resident #1?s ISP and that they did not have staff adequate in knowledge and sufficient numbers on that date to provide services.
Plan of Correction:	Steps to correct the noncompliance with the standard Staff #1 is no longer employed with The Gardens of Virginia Beach. DRC/designee will audit current residents ISPs to identify which resident?s service plan indicates that they are a 2 person assist with transfers. Measures to prevent the noncompliance from occurring again Current nursing staff will be re-educated to location of information regarding a resident?s transfer status, the number of people required to assist with transfer and what to do it another team member cannot be located to assist with transfer. DRC/designee will monitor nursing staff?s knowledge of a residents transfer status and where to find the information by asking 10 nursing staff members a week for 4 weeks with at least 2 on night shift, then 10 staff members monthly for 2 months, where to find a resident?s transfer information and how to find out how many staff need to assist the resident during transfers. Beginning 04/06/2020 and ending on 06/30/2020