VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Golden Care Services, LLC
532 Settlers Landing Road
Hampton, VA 23669
(757) 768-6046

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: March 8, 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 22VAC40-80 THE LICENSE

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/08/2024 (6:35 am/arrival ? 11:01 am/departure) 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: 5 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: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector reviewed resident and staff records, medication administration records, first aid kit, emergency preparedness and response plan, and fire drills. 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 Alexander Flint, Licensing Inspector at (757) 807-9731 or by email at Darunda.a.flint@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-490-A
Description:	Based on record review and staff interview, the facility failed to ensure the assisted living facility shall retain a licensed health care professional who has at least two years of experience as a health care professional in an adult residential facility, adult day care center, acute care facility, nursing home , or licensed home care or hospice organization, either by direct employment or on a contractual basis, to provide on-site health care oversight. Evidence: 1.During the onsite inspection, staff #1 acknowledged that there was no documentation of health care oversight at the facility to be reviewed.
Plan of Correction:	The healthcare oversight documentation was with Nurse who performed oversight. Documentation will be done electronically going forward to prevent documentation not being accessible for inspection purpose. Administrator will ensure documentation is available electronically.
Standard #:	22VAC40-73-640-D
Description:	Based on observation, the facility failed to ensure in addition to the facility's written medication management plan, the facility shall have readily accessible at least one pharmacy reference book, drug guide, or medication handbook for nurses that is no more than two years old as reference materials for staff who administer medications. Evidence: 1. During the inspection , the medication cart contained a 2021 version of a medication reference book. 2. Staff #1 acknowledged that the medication reference book was a 2021 version.
Plan of Correction:	Purchase of a new Drug book was an oversight on administrator end. Pill book was readily available for reference however a 2024 pill book has been ordered and received at facility.
Standard #:	22VAC40-73-680-E
Description:	Based on record review and staff interview, the facility to ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. The documentation shall be maintained in the resident?s record. Evidence: 1. The blood pressure procedure was not documented as completed on the March 2024 Medication Administration Record (MAR) for resident #1 03/01/24 through 03/07/24 as evidence by holes/blank spaces on the MAR. 2. Staff #1 acknowledged that resident #1?s March MAR did not have documentation of the aforementioned.
Plan of Correction:	After review of documentation administrator noted BP was being recorded on wrong sheet. RMA corrected and will ensure by double checking documentation.
Standard #:	22VAC40-73-860-G
Description:	Based on observation and staff interviewed, the facility failed to ensure the hot water taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F. Evidence: 1. During a tour of the facility with staff#1 the hot water temperature was obtained in the residents? downstairs and upstairs bathrooms. The temperature reading was 122.9 degrees F in the residents? downstairs bathroom, and the temperature reading was 121.8 degrees F in the upstairs residents? bathroom. 2. Staff #1 acknowledged the water temperatures were not within the required temperature range.
Plan of Correction:	Maintenance was called and adjusted thermostat on water heater. Maintenance will come monthly to do separate water temp check to make sure it falls within regulations and will adjust as needed.
Standard #:	22VAC40-73-920-D
Description:	Based on observation, the facility failed to ensure sturdy safeguards shall be provided, with installation in compliance with the Virgnia Uniform Statewide Building code to include handrails inside and stools available to stall showers. Evidence: 1. During a tour of the facility, the resident?s downstairs and upstairs stall showers did not have handrails inside them. 2. Staff #1 acknowledged the resident?s downstairs and upstairs stall showers did not have handrails inside them.
Plan of Correction:	Both restrooms have handrails installed in them, however new handrails inside of shower has been added to correct this citation. Maintenance will ensure placement is secure
Standard #:	22VAC40-73-950-E
Description:	The facility failed to develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual?s respective responsibilities. The review shall be documented by signing and dating. Evidence: 1. Staff #1 provided documentation of a semiannual review of the emergency preparedness and response plan for staff dated 06/30/2023.
Plan of Correction:	Training documentation signature was an oversight on administrator end. To ensure this won?t happen again all annual and semiannual training has been added to the Record of staff training and Education following employment sheet. Late entry signature made for that training as it was completed.
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the first aid kit included items with expiration dates that must not have dates that have already passed. Evidence: 1. The first aid kit was checked with staff #1. The first aid kit hand wipes expired March 2023. 2. Staff #1 acknowledged the first aid hand wipes were expired March 2023.
Plan of Correction:	The expiration dates on Hand wipes were not visible to staff on duty. The Licensing Inspector showed staff how to see embedded dates. New wipes purchased and replaced. Staff trained how to see dates on wipes if present.