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: March 9, 2023

Complaint Related: No

Areas Reviewed:

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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An announced monitoring inspection took place on 03/09/2023 from 8:55 am to 10:30 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A (self-reported incident) was received by VDSS Division of Licensing on (02/03/2023) regarding allegations in the area(s) of: Personnel Number of residents present at the facility at the beginning of the inspection: 108 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of a resident?s room, and staff were observed interacting with residents. 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 #:	22VAC40-73-110-1
Description:	Based on the staff interview and record review the facility failed to ensure all staff shall be considerate and respectful of the rights, dignity, and sensitiveness of persons who are aged, infirm, or disabled. Evidence: 1. Staff #3 acknowledged hearing staff #1 communicate profanity and inappropriate words towards resident #1. 2. Resident?s #1?s incident report dated 02/02/23 documents staff # 1 ?made an unkind statement to the resident.? The incident report documented staff #1 ?has been removed from the community and will be a Do Not Return.? 3. Staff # 2 and staff # 3 acknowledged resident #1 communicated to them his discomfort and feeling of disrespect with the profanity and inappropriate words communicated to him by staff #1.
Plan of Correction:	Person was an agency staff member from Gale Healthcare Solutions. The Agency staff member was sent out of the community on 2/2/23. Gale Healthcare Solutions was alerted of the Incident. APS and DSS were notified of the incident. Agency worker was marked as a Do Not Return and will not be allowed back into the community.
Standard #:	22VAC40-73-120-C
Description:	Based on the record review the facility failed to ensure all staff shall be trained in the relevant laws, regulations, and the facility?s policies and procedures sufficiently to implement requirements regarding the rights and responsibilities of residents. Evidence: 1. The record for staff #1 did not contain documentation of a training or review of the rights and responsibilities of residents.
Plan of Correction:	All agency staff that enter community starting 3/9/23 will sign a copy of the Resident?s Rights and will be kept on file in the Director of Resident Care?s office.