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: July 25, 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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 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 07/25/2023 from 8:16 am to 5:00 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:111 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: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast, lunch, and an activity were observed. A medication pass observation was completed for four residents. Water temperatures were measured. The signaling system was monitored. 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. 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) 822-9957 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on the record review the facility failed to ensure prior to admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. The record for resident #8 contains an assessment of serious cognitive impairment dated 08/02/21 which includes a response of ?No? for the question: is the individual unable to recognize danger or protect his/her own safety and welfare. The record documents a safe secure unit admission date of 08/06/21. 2. The record for resident #5 does not contain documentation of an assessment for serious cognitive impairment. The record documents an admission to the safe, secure unit on the date of 11/26/22, and an approval for placement in the safe, secure unit dated 11/11/22.
Plan of Correction:	Date of Correction- PCP for resident #8 will conduct reassessment on 8/21/23. PCP for resident #5 will conduct reassessment on 8/21/23. Plan of Correction- Going forward all Serious Assessments for Cognitive Impairment for all new admissions into our memory care community will be checked the Director of Resident Care or designee and then reviewed by the Executive Director for correctness prior to move in.
Standard #:	22VAC40-73-210-B
Description:	Based on record review the facility failed to ensure in a facility licensed for both residential and assisted living care, direct care staff who are certified nurse aides shall attend at least 12 hours of annual training. Evidence: 1. The record for staff #3, hired 04/05/19, did not include documentation of 12 hours of annual training.
Plan of Correction:	Date of Correction- Will have employee compliant with necessary remaining training by 9/15/23. Plan of Correction- Starting 8/21/23 random training audits will be conducted by the Business Office Manager or designee through 12/31/23. Each month 10 employee files will be audited for compliance with training.
Standard #:	22VAC40-73-210-D
Description:	Based on the staff record review the facility failed to ensure training for medication aides include continuing education required by the Virginia Board of Nursing, Evidence: 1. The Regulations Governing the Registration of Medication Aides by Virginia Board of Nursing, section 18VAC90-60-100-B, state that a medication aide shall have four hours each year of population-specific training in medication administration in the assisted living facility in which the aide is employed; or a refresher course in medication administration offered by an approved program 2. The record for staff #3, hired 04/05/19, a licensed medication aide (license effective date 10/07/16), did not contain documentation of completion of the continuing education required by the Virginia Board of Nursing.
Plan of Correction:	Date of Correction- Will have employee compliant with necessary continuing education training by 9/30/23. Plan of Correction- By 9/15/23 the Director of Resident Care will have audited all medication aides for compliance with continuing education training. The Business Office Manager will create a tickler by 9/30/23 that will keep record of each employees training anniversary review date.
Standard #:	22VAC40-73-450-C
Description:	Based on the record review the facility failed to ensure the ISP includes a description of identified needs based upon the UAI. Evidence: 1.Resident #2?s UAI dated 06/30/23 documents a mechanical help need for bathing. The ISP dated 06/30/23 does not include documentation of the mechanical help needed for bathing. 2.Resident #3?s UAI dated 02/08/23 documents mechanical help needed for stairclimbing and human help supervision needed for mobility. The ISP dated 02/08/23 does not include documentation of the mechanical help needed for stairclimbing and the human help needed for mobility.
Plan of Correction:	Date of Correction- Resident #2?s ISP was updated 8/17/23. Plan of Correction- Going forward Director of Resident Care and Assistant Director of Resident Care will review each other?s ISPs upon completion for correctness.
Standard #:	22VAC40-73-450-E
Description:	Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed by the resident or his legal guardian. Evidence: 1.Resident #4?s ISP dated 05/05/23 was not signed by the resident or the legal guardian. 2. Resident #5?s ISP dated 07/17/23 was not signed by the resident or the legal guardian. 3. Resident #6?s ISP dated 05/05/23 was not signed by the resident or the legal guardian. 4. Resident # 7?s ISP dated 05/11/23 was not signed by the resident or the legal guardian. 5. Resident # 8?s ISP dated 07/06/23 was not signed by the resident or the legal guardian. 6. Resident # 9?s ISP dated 07/24/23 was not signed by the resident or the legal guardian.
Plan of Correction:	Date of Correction- Resident #5?s ISP was signed on 8/17/23, Resident #4?s ISP was signed on 8/10/23. Assistant Director of Resident Care has reached out to resident?s #6, #7,#8,#9 for signing. Awaiting response from families. Will have all ISPs signed by 9/30/23. Plan of Correction- Going forward Director of Resident Care or designee when unable to get in person signatures will document attempts made on ISP to families to sign and send ISPs through email with request for electronic signature.
Standard #:	22VAC40-90-40-C
Description:	Based on the onsite record review the facility failed to ensure any person required to obtain a criminal history report shall be ineligible for employment if the report contains convictions of barrier crimes. Evidence: 1. Staff #5, hired 06/06/23, criminal record report contains two convictions for barrier crimes (18.2-57).
Plan of Correction:	Date of Correction- Employee was terminated on 9/1/23. Plan of Correction: Regulation was reviewed by the Executive Director with the local licensing Inspector and the Licensing Administrator. Feedback was then provided to the on-site Human Resources Manager and 5 Star Senior Livings Regional Human Resources for future compliance.