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: May 14, 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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 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 05/14/24 from 09:12 am to 02:17 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 03/25/24, 03/27/24, 03/28/24, 04/12/24 and 04/25/24, 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: 106 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 0 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 investigation supported some, but not all of the allegation?s 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 #:	22VAC40-73-460-B
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure care provision and service delivery shall be resident centered to the maximum extent possible and include prompt response by staff to resident needs as reasonable to the circumstances. Evidence: 1. Resident?s #3 call bell logs for the month of April, and May 2024 documented the facility did not promptly respond to the resident?s pendant alert system on the following dates and times: 4/03 @ 7:07 am, wait time (69 mins.) 04/04 @ 6:09 pm, wait time (93 mins.) 04/12 @ 3:50 am, wait time (105 mins.) 04/22 @ 8:00am, wait time (172 mins.) 05/03 @ 10:11 pm, wait time (86 mins) Resident?s #3 UAI and ISP dated 09/02/23 documents the resident needs physical assistance and mechanical help with bathing, toileting, and wheeling. 2. During an interview with resident #3, resident #3 stated she uses her pendant alert system when needing assistance with getting out of the bed in the morning and using the bathroom. Resident #3 stated on several days the staff has taken longer than one hour to respond to the resident?s pendant alert system, which has resulted in involuntary urination. Resident?s #3 physician exam dated 08/14/23 documents the resident as non-ambulatory and the use of a wheelchair.
Plan of Correction:	Resident #3 is no longer a resident in the community. Immediately a print out of the Call Bell report from the previous day was begun to be delivered to the Executive Director or designee for review. In services will be held with all care staff reviewing the expectations of answering call bells. Environmental Services Director will do a complete community audit of all pull stations in resident apartments to assure all are functioning properly. Responsible party: Executive Director
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 #1 contains a physician order dated 03/07/24 that includes the following: ?Fiasp Flextouch SUV, Latex free- 100 unit/1ML Insulin Pen, Inject 3 Units SQ TID Before Meals. Take an additional 1 unit for every 50 points over 200 for high sugars. Max daily dose 50 units.? The facility?s investigation report for resident #1 includes the following: ?the resident did not receive her insulin dose on April 6, 2024 at the lunch meal or at the dinner meal;? ?On April 7, 2024, the resident was not given Insulin for her morning/noon meals and by dinner her BS was over 300. The (resident?s child) called 911 and had the resident taken to the ER.?
Plan of Correction:	Resident #1 is no longer at the community. The Physician and POA for Resident #1, were notified of the missed insulin doses. The Pharmacy was contacted on 4/5/24, no insulin was sent. The pharmacy was contacted again on 4/6/24 and arrived the same day that evening. 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-I
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure the Medication Administration Record (MAR) should include: Any medication errors or omissions, Exact dose given, and 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. Resident?s #1 April 2024 MAR did not include the exact dose given for administering Insulin according to the physician order dated 03/07/24, ?Fiasp Flextouch SUV, Latex free- 100 unit/1ML Insulin Pen, Inject 3 Units SQ TID Before Meals. Take an additional 1 unit for every 50 points over 200 for high sugars. Max daily dose 50 units.? 2. Resident?s #1 April and May 2024 MAR, did not include reason for omission on the following dates and times for the resident?s prescribed order of ?Fiasp Flextouch SUV, Latex free- 100 unit/1ML Insulin Pen, Inject 3 Units SQ TID Before Meals. Take an additional 1 unit for every 50 points over 200 for high sugars. Max daily dose 50 units? for the following dates and times: 04/03/24 @ 7am 04/04/24 @ 7am and 11am 04/06/24 @ 4pm 04/07/24 @ 11 am and 4pm 04/11/24 @ 11am 04/13/24 @ 11am 04/14/24 @ 11am 04/16/ 24 @ 11am 04/18/24 @ 7am and 11am 05/04/24 @ 7am, 11am, and 4pm 05/05/24 @ 7am, 11am, and 4pm 05/06/24 @ 7am and 11am 05/08/24 @ 7am and 11am 05/09/24 @ 7am and 11am 05/10/24 @ 4pm 05/11/24 @ 4pm. 3. The April and May 2024 MARs for residents #1 and #2, did not include the name, signature, and initials of all staff administering medications, and/ or a master list. 4. Resident?s #2 April 2024, MAR did not include reason for omission on the following dates for the resident?s prescribed order dated 02/23/24, ?Lantus Solostar Unit/1ML Insulin Pen, Inject 20 units Subcutaneously every evening.? 04/01/24 04/18/24 04/23/24 04/24/24 04/26/24.
Plan of Correction:	22VAC40-73-680-I Resident #1 is no longer a resident in the community. 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