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: Jan. 30, 2024

Complaint Related: Yes

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 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 01/30/24 from 09:40 am to 02:08 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/05/2024 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, and the Safe, Secure Environment 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: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: The call signaling system was monitored, and verification of the staffing schedule was completed. 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 #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian. Evidence: 1. Resident?s #2 ISP revised on 11/29/23 was not signed and dated by the facility and the resident or the legal guardian. 2. Resident?s #3 ISP revised on 08/21/23 was not signed and dated by the facility and the resident or the legal guardian.
Plan of Correction:	1.The ISP for Resident #2, revised 11/29/23, will be signed and dated by the Administrator and the POA. The ISP for Resident #3, revised on 8/21/23, will be signed and dated by the Administrator and the POA/legal guardian/resident. 2.An audit of ISPs will be completed by the Administrator, or designee, for signatures and dates per state regulation and 5 Star Policy. ISPs requiring signatures and dates will be presented to the POA/legal guardian/resident. 3.The Director of Resident Care, or designee, will audit 10% of resident ISPs every month, for signatures from the resident/legal guardian/POA and the administrator or his designee. The staff will be re-educated on obtaining signatures of POA/legal guardian/resident and administrator or his designee when updating/revising resident ISP.
Standard #:	22VAC40-73-930-D
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure for each resident with an inability to use the signaling device the following shall be met: once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum direct care staff shall make rounds no less than every two hours; the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. The documentation shall be retained at the facility for two years. Evidence: 1. Residents #1, #2, and #3 ISP documents the following: ?resident requires visual checks, hourly checks, night checks.? The record for residents #1, #2, did not include documentation rounds were made for the following dates and timeframes: 01/04/24, 01/07/24, 01/13/24, 01/20/24. 01/23/24, 01/25/24, and 01/28/24 during the 11pm-7am shift. Resident #1 and #2 reside in the facility?s safe secure environment. 2.The record for resident #3 did not include documentation rounds were made for the following dates and timeframes: 01/03/24, 01/08/24, and 01/12/24 during the timeframe of 11pm -7 am. Resident #3 reside in the facility?s safe secure environment.
Plan of Correction:	1.The staff assigned in Memory Care have been re-educated in making rounds and documenting the date and times of rounds for each resident with an inability to use the signaling device once the resident has gone to bed until the resident has arisen. 2.A Resident Rounds binder with a documentation chart for each resident in Memory Care will be created. The chart will include the resident name, the date and time of the rounds, and the staff member who is making the rounds. The Memory Care Director, or designee, will audit the binder daily and report deficient documentation to the Director of Resident Care. 3.The Director of Resident Care, or Designee, will audit the Resident Rounds binder weekly, for documentation per state regulations. The documentation will be maintained for 2 yrs with the Director of Resident Care.