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: Nov. 18, 2020 and Nov. 19, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on November 13, 2020 and concluded on November 19, 2020. A complaint was received by the department regarding allegations in the areas of resident care and related services. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Executive Director a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. The complaint is not valid. Consultation provided on documentation of actions taken when alleged incidents occur, incident reporting, and allergy reactions on physical examination forms was reviewed.

Violations:

Standard #:	22VAC40-73-1110-A
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee determined whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident's file. Evidence: 1. The following residents admitted to the Safe, Secure Environment (SSE) and had no determination and justification for placement by the licensee, administrator, or designee. A. Resident #1 admitted 12-11-19, B. Resident #2 admitted 09-09-19, and C. Resident #3 admitted 07-03-19. 2. Staff #1 confirmed during discussion the determination and justification for placement by the licensee, administrator, or designee had not been completed for the three residents mentioned.
Plan of Correction:	Steps to correct the noncompliance with the standard The Executive Director and/or designee will conduct a review to ensure residents admitted to the SSE within the last six months have the appropriate documentation in their record reflecting their determination and justification for placement into the SSE. Measures to prevent the noncompliance from occurring again The Executive Director and/or designee will review a new admission?s Approval for Placement in Special Care Unit DSS Form 032-05-0082-03-eng prior to admission to ensure determination and justification are present on the form. The Executive Director is responsible for the implementation of each step and/or monitoring preventative measures.
Standard #:	22VAC40-73-320-B
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure a risk assessment for tuberculosis was completed annually on each resident as evidenced by the completion of the current screening form. Evidence: 1. Resident #2 admitted 09-09-2019 to the facility. Resident did not have a completed annual tuberculosis screening on file at the time of inspection. 2. Staff #1 confirmed the annual tuberculosis form was not signed by the screener or dated to indicate what date the screening was completed.
Plan of Correction:	Steps to correct the noncompliance with the standard A tuberculosis annual risk assessment review will be completed for residents residing on the Special Care Unit (BTR). Measures to prevent the noncompliance from occurring again The DRC and Assistant DRC will be educated on the annual tuberculosis risk assessment protocol by the Executive Director/Designee. Person(s) responsible for implementation of each step and/or monitoring preventative measures The DRC (The Bridge to Rediscovery Program Manager) and/or designee will complete a monthly tuberculosis risk assessment review for three months. The Executive Director is responsible for the implementation of each step and/or monitoring preventative measures.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. Evidence: 1. The following residents? medications were not administered in accordance with the physician?s or other prescriber?s instructions according to their Medication Administration Records (MARs): A. Resident #1 ? Dronabinol 04-27-20 9:00 a.m. and 6:00 p.m., Glucerna 04-24-20 ? 04-26-20 9:00 a.m., 1:00 p.m., and 6:00 p.m. and 04-27-20 9:00 a.m. and 1:00 p.m., Mirtazapine F/C and Quetiapine Fumarate F/C on 04-24-20 at 8:00 p.m.; B. Resident #2 ? Acetaminophen 04-24-20 and 04-25-20 8:00 a.m., Omeprazole 04-03-20 ? 04-05-20 8:00 p.m. and 04-04-20 ? 04-06-20 8:00 a.m.; and C. Resident #3 ? Polyethylene Glycol 03-16-20 ? 03-18-20 8:00 a.m., Magnesium and Buspar 03-29-20 at 8:00 p.m. 2. Staff #1 confirmed during discussion the aforementioned medications were not administered in accordance with the physician?s or other prescriber?s instructions.
Plan of Correction:	Steps to correct the noncompliance with the standard A Medication Administration Record (MAR) review will be completed for residents residing on the Special Care Unit (BTR). Measures to prevent the noncompliance from occurring again Licensed Clinical Staff and Medication Aides will be re-educated on medication refill management practices by the Director of Resident Care/Designee. Person(s) responsible for implementation of each step and/or monitoring preventative measures The Director of Resident Care(DRC) and/or designee will conduct a weekly MAR review for four weeks, then monthly for two months to validate that medications are given as prescribed and obtained timely from pharmacy or family when refills are needed. The Executive Director is responsible for the implementation of each step and/or monitoring preventative measures.