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: 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

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 01/30/2024 from 9:40 am to 2:08 pm. 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 (01/19/2024) 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: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of the assisted living and safe, secure environment 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 #:	22VAC40-73-110-1
Description:	Based on the onsite 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. Resident?s #1 incident report dated 01/19/24 includes documentation of resident #1 hearing staff #1 refer to resident #1 with the use of a curse word and the word ?idiot.? The facility terminated staff #1 on 01/22/24.
Plan of Correction:	1.Staff members will receive re-training on Resident Rights. 2.Staff are assigned yearly re-training on Resident Rights. The Business Office Manager will audit staff education folders for appropriate 12 hrs of in-service documentation and if necessary, assign deficient staff work hours to complete their required training. 3.The Administrator, or designee, will audit 25% of staff education folders, quarterly, for attendance of at least 12 hrs of annual training. Staff will be given training time to complete their training per state regulation and 5 Star Policy.
Standard #:	22VAC40-73-210-B
Description:	Based on the 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 #1, hired 04/05/19, did not include documentation of 12 hours of annual training. 2. Staff #1 training record documented 4.9 hours of annual training during the timeframe of 04/05/22-01/22/24.
Plan of Correction:	1.An audit of staff files will be completed and staff who have not completed their required training will be assigned work hours to completed the training. 2.The Business Office Manager will audit staff education folders for appropriate 12 hrs of in-service documentation and if necessary, assign deficient staff work hours to complete their required training. 3.The Administrator, or designee, will audit 25% of staff education folders, quarterly, for attendance of at least 12 hrs of annual training. Staff will be given training time to complete their training per state regulation and 5 Star Policy.