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: Feb. 29, 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 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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 02/29/2024 from 10:20 am to 02:34 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 02/01/2024 and 02/29/2024 regarding allegations in the area(s) of: Staffing and Supervision, and Resident Care and Related Services 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: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Lunch was observed, and the call signaling system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. The record for resident #2 contains the following: a physician order dated 08/17/23, 10/02/23, and 11/30/23 for ?Coumadin 5mg, take 1 tablet by mouth every day;? a physician order dated 10/03/23 for Coumadin 5 mg, ?hold coumadin 10/2/23, 10/3/23, then start Coumadin 5mg.? Resident?s #2 medication administration record (MAR) does not include documentation the resident was administered Coumadin on the following dates: 09/07/23, 09/29/23, 10/04/23, 10/08/23, 10/18/23, 11/14/23, 12/01/23, 12/10/23, 12/11/23, 12/13/23, 12/14/23, 12/19/23. 2. The record for resident #3 contains a physician order dated 03/06/23 for ?atorvastatin calcium 80mg, take 1 tablet by mouth every day.? Resident?s #3 MAR does not include documentation the resident was administered atorvastatin calcium on the following dates: 09/07/23, 11/22/23, 11/24/23, 11/26/23, 11/27/23, 12/17/23, 19/19/23, 12/22/23. 3. The record for resident #3 contains a physician order dated 03/06/23 for ?carbidopa-levodopa 25-100mg, take 1 tablet by mouth three times daily.? Resident?s #3 MAR does not include documentation the resident was administered carbidopa-levodopa 3 times daily on the following dates: 09/07/23, 10/02/23, 10/09/23, 10/15/23, 10/20/23, 10/23/23, 10/25/23, 10/26/23, 10/28/23, 10/29/23, 11/22/23, 11/24/23, 11/25/23, 11/26/23, 11/27/23, 11/30/23 12/05/23, 12/06/23, 12/10/23, 12/22/23, 12/16/23, 12/19/23, 12/30/23. 4. 2. The record for resident #3 contains a physician order dated 03/06/23 for ?amlodipine 5 mg, take 1 tablet by mouth every day.? Resident?s #3 MAR does not include documentation the resident was administered amlodipine on the following dates: 10/23/23, 10/25/23, 10/29/23, and 11/26/23.
Plan of Correction:	Resident #2 is no longer a resident in the community. The Physician and POA for Resident #3, were notified of the missed medications, Atorvastatin Calcium, Carbidopa-levodopa, and Amlodipine. No new orders were obtained from the physician. An audit of MARs will be completed by the Director of Nursing, or designee, for documentation of medication administration. The clinical staff will be re-educated on documenting medication administration in the MARs. The Director of nursing, or designee, will audit MARs every month, for documentation of medication administration. Missed documentation will result in further re-education of the staff. Responsible party: Director of Nursing
Standard #:	22VAC40-73-680-E
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided accorded to his instructions and documented. The documentation shall be maintained in the resident?s record. 1. The record for resident #2 contains a physician order dated 10/23/23 that includes the following instructions: Coumadin 5mg, recheck PT/INR 2 weeks. The resident?s record did not contain documentation the resident?s PT/INR was checked 2 weeks after the date of 10/23/23 or for the month of Nov. 2023. 2. Staff #5 acknowledged, the record for resident #2 did not contain documentation the resident?s PT/INR was checked 2 weeks after the date of 10/23/23 or during the month of Nov. 2023.
Plan of Correction:	Resident #2 is no longer a resident in the community. The physician and POA were notified of the missed medical procedure on 10/23/23, no new orders were given. An audit of resident healthcare practitioner orders for medical procedures will be completed by the Director of nursing, or designee, to ensure medical procedures or treatments have been followed as ordered. The clinical staff will be re-educated on following the healthcare practitioner?s orders for medical procedures or treatments when they are ordered. The Director of Nursing, or designee, will audit resident healthcare practitioner orders for medical procedures or treatments every month for documentation of completion of the orders. The Healthcare practitioner and the POA will be notified of missed orders for treatments or medical procedures and new orders will be obtained if applicable. Responsible party: Director of Nursing
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on the record review the facility failed to ensure the MAR should include the name, signature, and initials of all staff administering medications. A master list may be used in lieu of this documentation on individual MARS. Evidence: 1. The MARs for residents #2 and #3 did not include the name, signature, and initials of all staff administering medications, and/ or a master list.
Plan of Correction:	Resident #2 is no longer a resident in the community. The MAR for resident #3 was updated with the name, signature, and initials of the staff administering medications. The Director of nursing, or designee, will audit the resident MARs for names, signatures and initials of staff administering medications. The staff administering medications will be re-educated on documenting their name, their signature, and their initials on the MARs. A Master list of names, signatures and initials will be created by the Director of Nursing, of staff administering medications. The Director of Nursing, or designee, will audit the Master list to ensure staff who are administering medications, have their name, signature, and initials on the Master list. Responsible party: Director of Nursing