VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Huntington
11143 Warwick Boulevard
Newport news, VA 23601
(757) 223-0888

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: July 18, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 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: 07/18/2024 (arrival 9:07am/ departure 4:32pm) 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: 31 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of a meal and the assisted living unit was completed. Additional Comments/Discussion: 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 Darunda Flint, Licensing Inspector at (757)807-9731 or by email at Darunda.a.flint@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-120-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a staff?s record included documentation of orientation and training required within the first seven working days of employment. Evidence: 1. Staff #6?s record included documentation of orientation and training conducted on 03/25/2024. Staff #6?s date of hire documented as 03/12/2024. 2. Staff #2 acknowledged staff #6?s documented date of required orientation and training did not occur within the first seven working days of employment.
Plan of Correction:	1. Staff #6?s orientation and training were completed but it was after the 7 required days. 2. Staff responsible for new hire orientation were re-educated on required orientation and training guidelines. 3. The Administrator/designee will perform weekly audits for 6 weeks to ensure 100% of new hire employees from the previous week have orientation and training completed timely.
Standard #:	22VAC40-73-250-D
Description:	Based on staff records reviewed, the facility failed to ensure each staff person member?s tuberculosis (TB) risk assessment be completed annually. Evidence: 1.The TB risk assessment form for Staff member #3 was dated 05/18/2023 and 5/25/2023. There is no evidence in the record of a risk assessment for TB being completed annually. 2. Staff #4 acknowledged the aforementioned TB assessment dates.
Plan of Correction:	1. The TB risk assessment form for staff #3 was completed on 7/19/24. 2. The Resident Care Coordinator was educated on ensuring staff had annual TB risk assessments completed. 3. The Director of Nursing/designee will perform weekly audits on 5 staff members to ensure TB risk assessments are being completed annually.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #3 (hire date 08/21/2023) had first aid certification which expired February 2024. Staff #3 does not have a current certification in first aid. 2. Staff #5 acknowledged the aforementioned expired first aid certification.
Plan of Correction:	1. Staff #3 has been enrolled in first aid training and will be completed by 8/22/2024. 2. All nursing staff were re-educated on needing to keep their first aid and/or CPR up to date as applies to their role. 3. The Director of Nursing/designee will perform weekly audits of 3 staff members for 6 weeks to ensure staff members are current with their first aid training.
Standard #:	22VAC40-73-320-B
Description:	Based on record review, the facility failed to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident. Evidence: 1.The TB risk assessment for resident #2 was incomplete there was no signature and date for the person who completed the assessment.
Plan of Correction:	1. The TB risk assessment form for resident #2 was updated on 7/26/24. The TB risk assessment form for resident #3 was located in the electronic medical record on 7/22/24. 2. The Resident Care Coordinator was educated on ensuring residents have an annual TB risk assessment completed annually. 3. The Director of Nursing/designee will perform weekly audits of 5 residents to ensure TB risk assessments are being completed annually.
Standard #:	22VAC40-73-440-B
Description:	Based on record review, the facility failed to ensure for private pay individuals, the administrator or the administrator's designated representative approves and then signs the completed UAI. Evidence: 1. The UAI for resident #3 (dated 12/01/2023) did not have an approved and signed signature by the administrator or the administrator?s designated representative. 2. Staff #2 acknowledged the aforementioned resident?s UAI did not have a signed signature by the administrator or administrators designated representative.
Plan of Correction:	1. The UAI for resident #3 was signed by the administrator on 7/19/24. 2. The Resident Care Coordinator and Administrator were re-educated on ensuring the completed UAI is signed by the administrator or the administrator?s designated representative. 3. The Director of Nursing/designee will a perform monthly audit of 100% of UAIs completed in the previous month for 3 months to ensure the UAI has an administrator?s signature.
Standard #:	22VAC40-73-450-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator or designee and the resident or legal representative. Evidence: 1. Resident #2?s ISP (dated 07/09/2024), and resident #3?s ISP (dated 06/04/2024) were not signed and dated by administrator or designee. 2. Staff #2 acknowledged the aforementioned resident?s ISPs were not signed and dated by the administrator or designee
Plan of Correction:	1. The ISPs for residents # 2 and #3 were signed by the administrator on 7/19/24. 2. The Resident Care Coordinator was re-educated on ensuring the ISP is signed when completed. 3. The Director of Nursing/designee will a perform monthly audit of 100% of ISPs completed in the previous month for 3 months to ensure the ISP has the licensee?s signature
Standard #:	22VAC40-73-580-A
Description:	Based on record review, the facility to ensure when any portion of an assisted living facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as evidenced by an initial and subsequent annual report from the Virginia Department of Health. The report shall be retained at the facility for a period of at least two years. Evidence: 1. On 07/18/2024, the most recent health department inspection was dated 12/19/2022. There was no health department inspection for 2024. 2. Staff #4 acknowledged the aforementioned expired health department inspection.
Plan of Correction:	1. The inspection by the Virginia Department of health was completed on 7/23/24. 2. The Administrator was re-educated on ensuring the health department inspection is completed annually. 3. The Administrator/designee will ensure that the health department inspection is completed annually.
Standard #:	22VAC40-73-640-D
Description:	Based on observation and staff interviewed, the facility failed to ensure the pharmacy reference book, drug guide, or medication handbook for nurses is no more than two years old. Evidence: 1.The reference drug handbook on the assisted living unit was a 2021 reference drug handbook. 2.Staff #1 acknowledged the reference drug handbook was more than two years old.
Plan of Correction:	1. An updated drug reference book was obtained for the facility on 7/30/24. 2. Nursing Administration was educated on needing to have an updated drug reference book available at the facility that is no more than 2 years old. 3.The Director of Nursing/designee will ensure a new drug reference book is obtained annually.
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the first aid kit included all times. Items with expiration dates must not have dates that have already passed. Evidence: 1. The first aid kit in the building was checked with staff #2. The first aid kit did not have gauze pads and roller gauze, in assorted sizes. 2. The first aid kit on the vehicle was checked with staff #2. The first aid kid did not have plastic bags. 3. Staff #2 acknowledged the items were not in first aid kit.
Plan of Correction:	1. The gauze pads and roller gauze in the first aid kit was replaced on 7/18/24. The plastic bags in the first aid kit on the vehicle was replaced on 7/18/24. 2. Nursing staff were re-educated on what items must be kept in the first aid box and ensuring they replace any items removed from the first aid kit. 3. Director of Nursing/designee will perform weekly audits for 6 weeks to ensure all items are present in the first aid kit.