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: Aug. 30, 2022 and Sept. 1, 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 22VAC40-80 THE LICENSE

Technical Assistance:

Breakfast Menu & Weekly Breakfast Schedule

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 was initiated on 08/30/2022 from 8:15am to 3:30pm and on 09/01/2022 from 8:39am to 2:34pm. 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: 94 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 4 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Breakfast, 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 cart, emergency preparedness plan, fire inspection report, health inspection report, and a medication plan. Water temperatures were checked in two resident rooms. Call Bells for two residents were checked and staff responses were observed. 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 #:	22VAC40-73-210-B
Description:	Based on the onsite record review the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. Evidence: 1. The record for Staff #2 (Date of Hire (DOH)-04/05/19) did not include documentation of 18 hours of annual training. 2. The record for Staff #3 (DOH-02/01/16) did not include documentation of 18 hours of annual training. 3. Staff #7 acknowledged there is no evidence of documentation of 18 hours of annual training for Staff #2 and staff #3.
Plan of Correction:	Will have all employee training current by 1/1/23. An internal audit will be completed by the Executive Director or designee on all staff for training record compliance by 10/19/22. Going forward all training will be scheduled by the Business Office Manager or designee within 30 days of hire. Any employee who does not complete the required training will be removed from the schedule until completed. Community is currently assessing feasibility of an on-site staff training center for staff use.
Standard #:	22VAC40-73-260-A
Description:	Based on record review the facility failed to ensure each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection 260-A, shall receive certification in first aid within 60 days of employment. Evidence: 1. The record for Staff #1 (DOH-06/21/22) did not include documentation of certification in first aid. 2. Staff #7 acknowledged there is no evidence of documentation of certification in first aid for staff #1.
Plan of Correction:	Will have all employees certified by 12/1/22. An internal audit will be completed by the Executive Director or designee on all staff records on First Aid/CPR compliance. The Business Office Manager or designee will create an employee tickler by 10/1/22 to verify continued compliance. The first CPR/First Aid class has been scheduled for 10/8/22 for staff who do not have up current certifications. These classes will continue until all staff are current.
Standard #:	22VAC40-73-260-C
Description:	Based on observation and staff interviewed, the facility failed to ensure the posted listing of staff certifications in first aid or cardiopulmonary resuscitation (CPR) or both was kept up to date. Evidence: 1. Licensing Inspector (LI) observed on 9/01/22 the First Aid and CPR list posted in the facility documented a date of 8/31/22 however the list was not current. 2. The First Aid and CPR list did not include the First Aid and CPR dates for staff #3, and staff #5. The record for staff # 3 documents a certification in first aid of 2/17/19 and a certification in CPR as of 2/16/21. The record for staff #5 documents a certification in First Aid as of 8/24/21 and a certification in CPR as of 8/24/21. 3. Staff #7 acknowledged the First Aid and CPR list posted in the facility was not current.
Plan of Correction:	Corrected on 8/30/22 The business office manager or designee will perform an employee audit by 10/1/22 to stay current on the employee?s certifications. The business office manager or designee will audit employee certifications to verify continued compliance.
Standard #:	22VAC40-73-290-B
Description:	Based on observation the facility failed to develop and implement a procedure for posting the name of the current on site person in charge. Evidence: 1. Upon arrival at the facility on 08/30/22 at 8:15 a.m. the LI observed a posting that documented the manager on duty as staff #6. Staff #6 was not on site at the facility upon the LI arrival at the facility. 2. Staff #6 acknowledged the posting of the name of the current on site person in change was not updated to document the person in charge when staff # 6 was not on site at the facility.
Plan of Correction:	Corrected on 8/30/22 Plan of Correction- The name of the current on-site person in charge is posted at the front of the community. To remain in continued compliance, it will be the front desk employee?s or designee?s responsibility to post the name daily.
Standard #:	22VAC40-73-490-A-2
Description:	Based on staff interview the facility failed to ensure a licensed health care professional, practicing within the scope of his profession, shall provide healthcare oversight at least every three months, or more often if indicated, based on his professional judgement of the seriousness of a resident?s needs or stability of a resident?s condition. Evidence: 1. Staff #6 acknowledged the facility did not have a current health care oversight. 2. LI requested a copy of the most recent health care oversight completed for the facility. Staff #6 informed the LI the most recent health care oversight was not able to be located. When requested by the LI, staff #6 was unable to provide a date of when the most recent health care oversight was completed.
Plan of Correction:	A quarterly healthcare oversight will be completed by 1/1/23. Community is currently reviewing contracts with outside vendors to provide quarterly healthcare oversight for the community.
Standard #:	22VAC40-73-620-A
Description:	Based on record review and staff interview the facility failed to ensure there shall be oversight at least every six months of special diets by a dietitian or nutritionist for each resident who has such a diet. Evidence: 1. LI observed in the facility kitchen a posting titled ?special diets and residents with food allergies updated 8/19/22?, which documented the pictures, names of residents, and a list of allergies and diets for each resident pictured on the posting. 2. Per the posting located in the facility kitchen, resident #3 has a mechanical diet. Resident #11 has a pureed diet. Resident #14 has no tomato based food ?upsets her stomach.? 2. Staff #6 acknowledged the facility does not have documentation of a dietary oversight.
Plan of Correction:	A quarterly dietician summary will be completed by 12/1/22. Executive Director and Director of Resident have meeting scheduled with the community?s contracted dietician on 10/5/22 to discuss the information and services needed for residents with specialized diets per the DSS standards. This information will be included in all future dietician visit summaries.
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 medication on a medication cart at the facility: Hydralazine 25mg. tablets expired 2/7/2022 for resident # 1.
Plan of Correction:	The outdated medication was removed and disposed of on 8/30/22. Starting 9/29/22 Med cart audits will be conducted by the Director of resident care or designee weekly for four weeks, then every other week for four weeks, then monthly for four months to verify continued compliance.