VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Golden Years Assisted Living Facility, Inc.
40 Hunt Club Boulevard
Hampton, VA 23666
(757) 825-2425

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: April 8, 2024 , April 11, 2024 and April 16, 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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 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: 4/8/2024 7:56 am- 2:00 pm, 4/11/2024 7:30 am- 2:00 pm, 4/16/2024 1:46 pm- 4:52 pm 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: 77 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 6 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-120-A
Description:	Based on the review of facility records and interviews conducted with facility staff, the facility staff failed to ensure that the orientation and required training occurred within the first seven working days of employment. Evidence: 1. The staff orientation checklist for Staff members #1 and #3 were blank. 2. Staff #5?s record did not contain any documentation that the staff member received orientation.
Plan of Correction:	1. Counseling and re-education were provided to the staff members responsible for the new hire process. 2. All new staff have been hired and trained in the process for new hires. The administrator will review all new hire information along with the Business Office Manager to ensure that all documents are completed and signed.
Standard #:	22VAC40-73-250-C
Description:	Based on a review of staff records, the facility failed to verify that each staff person has received a copy of his or her current job description. Evidence: Staff members #1 and #5?s file did not contain documentation of a signed job description.
Plan of Correction:	1. Prior to final inspection date the administrator had begun auditing all employee files to bring them all into compliance. 2. All employees were given a new hire packet which included job descriptions, new 2024 tax forms, Resident Rights, and other required forms. 3. All employees were required to sign all new forms during the monthly mandatory staff meeting to ensure going forward that all employees remain in compliance.
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records the facility failed to ensure that each staff person submit the results of a tuberculosis (TB) risk assessment on or within seven days prior to the first day of work at the facility and that each staff person submit the results of a risk assessment annually. Evidence: 1. The files for Staff members #1 (D.O.H. 3/20/2024), #3 (D.O.H. 4/8/24), #5 (D.O.H. 12/18/2023), and #6 (D.O.H. 10/11/2021) did not contain TB risk assessments. 2. The file for Staff #4 did not contain an annual TB risk assessment. The most recent assessment was dated 1/28/2022. 3. The file for Staff #6 did not contain an annual TB risk assessment. The most recent assessment was dated 4/22/2022.
Plan of Correction:	1. An audit of all employee files was begun prior to the completion of this audit to bring all files into compliance, and to ensure that relevant documents are in each employee?s file. 2. A TB risk assessment has been completed on every employee to ensure that all employee records comply. 3. All employee files will be audited by the administrator quarterly according to month of hire to ensure that all files are complying.
Standard #:	22VAC40-73-290-B
Description:	Based on observation, the facility failed to ensure the posting of the name of the current on-site person in charge. Evidence: 1. On the date of the inspection 4/8/2024, there was no posting of the on-site person in charge. 2. Staff member #1 acknowledged there was no posting.
Plan of Correction:	1.Upon entering the facility. A board displaying the names, position, and phone numbers of each Leadership Member. 2. The board was updated prior to the final inspection date of this survey. At any time, if any of the leadership member change, the board will be updated to reflect the change immediately.
Standard #:	22VAC40-73-310-B
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure a documented interview between the administrator or designee responsible for admission and retention, the individual, and the legal representative, if any was in the record for a resident. Evidence: 1. Resident #5?s record did not include documentation of an interview. The Resident?s date of admission was 6/2/23.
Plan of Correction:	1. New processes have been put in place for all new admissions going forward, including the initial admission assessment which will be completed by the administrator and the Business Office Manager. 2. New admissions will be oriented to the facility by the administrator and again by the clinical staff during the initial head-to-toe evaluation process upon admission.
Standard #:	22VAC40-73-320-B
Description:	Based on the review of facility records with the facility Administrator, the facility failed to ensure that a risk assessment for tuberculosis was completed annually on each resident. Evidence: 1. Resident # 5?s date of admission was 6/2/23. The TB assessment in his chart dated 5/10/23 was incomplete as it did not state if the resident required TB testing. 2. Resident #3?s date of admission was 6/8/20. The file did not contain a TB evaluation for the licensing inspector to review. 3. Resident #6?s date of admission was 4/2/19. The most recent TB evaluation in the file was dated 6/18/21. 4. Resident #8?s date of admission was 3/18/19. The file did not contain a TB evaluation for the licensing inspector to review.
Plan of Correction:	1.TB risk assessment has been completed on each resident and placed in their records. 2. All new admission will TB risk assessments completed at the time of admission. 3. All TB assessment will be completed annually on all residents and placed in their charts.
Standard #:	22VAC40-73-410-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the record included an acknowledgement of having received the orientation and shall be signed and dated by the resident, and as appropriate the legal representative and shall be kept in the resident?s record. Evidence: On 4/8/24, Resident #5?s record did not include documentation of an orientation for new residents which included information regarding mealtimes, the use of the call system, and the emergency response procedures.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-A
Description:	Based on a review of resident records, the facility failed to ensure complete Uniform Assessment Instruments (UAIs) records were reviewed at least annually. Evidence: 1. The last documented UAI for Resident #1 was dated 2/9/2022. 2. The last documented UAI for Resident #2 was dated 3/23/2023. 3. The last documented UAI for Resident #3 was dated 11/3/2020 and there was no assessor signature. 4. The last documented UAI for Resident #7 was dated 2/28/2023 and there was no assessor signature. 5. The last documented UAI for Resident #8 was dated 3/21/2024 and there was no assessor signature. 6. The last documented UAI for Resident #9 was dated 11/10/2022 and there was no assessor signature. 7. The last documented UAI for Resident #10 was dated 3/1/2024. The resident?s date of admission was 5/25/2018. There were no UAI assessments documented in the resident file for 2022 or 2023.
Plan of Correction:	1. A quarterly review of resident?s files has been scheduled to ensure UAI?s are consistently up to date. 2. The facility is in the process of purchasing and EMR, which will allow us to receive alerts when UAI?s are due to be renewed. Until then, a spreadsheet with renewal dates is being created to facilitate tracking UAI?s renewals. 3. A new Business Office Manager along with a new Nurse Consultant has begun the process prior to the completion of this survey, auditing every resident UAI to bring them all into compliance. 4. All UAI??s will be setup on quarterly schedules according to their admission dates to better stay on top of this process going forward. 5. New tracking systems are also being incorporated.
Standard #:	22VAC40-73-440-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it was in compliance with the requirements set forth in 22VAC30-110. Evidence: On 4/11/24, Resident #5?s uniformed assessment instrument (UAI) dated 4/8/24 was completed by a facility staff. The document was not signed by the administrator or designee.
Plan of Correction:	1.Resident in question UAI has been signed by the Administrator. 2.All other resident records have been reviewed and the updated UAI?s are being signed by the Administrator. 3.An entirely new charting system is in the process of being implemented to ensure that all vital and pertinent information is in all resident files. 4.This process was begun prior to the completion of this survey. 5. Any outdated UAI?s have been sent to the appropriate agency for update and upon receiving the new updated UAI?s the Administrator will sign immediately.
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs. Evidence: The record for Resident #5 did not contain a comprehensive ISP.
Plan of Correction:	1.All resident medical records have been audited by a licensed contractor and all resident ISP?s have been updated according to standards. 2. The residents ISP will be placed on a spreadsheet according to their admission date for quarterly review, and when there is a change in the resident?s condition.
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs. Evidence: The record for Resident #5 did not contain a comprehensive ISP.
Plan of Correction:	1. All resident medical records have been audited by a licensed contractor and all resident ISP?s have been updated according to standards. 2. The residents ISP will be placed on a spreadsheet according to their admission date for quarterly review, and when there is a change in the resident?s condition.
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 resident or the legal representative. Evidence: 1. The ISP for Resident #3 with a review date of 3/22/24 did not contain a resident of legal representative signature. 2. The ISP for Resident #7 with a review date of 4/8/24 did not contain a resident of legal representative signature. 3. The ISP for Resident #9 with a review date of 3/1/2024 did not contain a resident or legal representative signature. 4. The ISP for Resident #10 with a review date of 3/25/24 did not contain a resident of legal representative signature.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on staff interview and review of resident records, the facility failed to update the ISP (Individualized Service Plan) at least once every 12 months. Evidence: 1. The ISP for Resident #1 had an end date timeframe of 4/2/2020. 2. The ISP for Resident #2 had an end date timeframe of 4/9/2022. 3. The ISP for Resident #6 was not reviewed every 12 months. The ISP was reviewed 8/4/22 and on 4/8/24. There was no review documented in 2023. 4. The ISP for Resident #9 was not reviewed every 12 months. The ISP was reviewed 4/1/2020 and on 3/1/2024. There were no annual ISP reviews documented for 2021, 2022, or 2023. 5. The ISP for Resident #10 was not reviewed every 12 months. The ISP was reviewed on 12/30/2021 and 3/25/2024. There were no annual ISP reviews documented for 2022 or 2023.
Plan of Correction:	1. A quarterly review of resident files has been scheduled to ensure ISPs are consistently up to date. 2. The facility is in the process of purchasing an EMR, which will allow us to receive alerts when ISPs are due to be renewed. Until then a spreadsheet with renewal dates will be created to facilitate tracking ISP documentation. 3. Prior to the date of this survey the facility hired a Nurse Consultant to begin auditing all residents Individualized Service Plans (ISP) and bring them into compliance. 4. The Administrator is registered to take the certification course on 08/08/2024 to become trained to become educated to assist in the ISP process that the facility remains in compliance going forward.
Standard #:	22VAC40-73-490-A
Description:	Based on staff interview the facility failed to ensure a licensed health care professional, practicing within the scope of his profession, shall provide healthcare oversight at least every three months, or more often if indicated, based on his professional judgement of the seriousness of a resident?s needs or stability of a resident?s condition. Evidence: On 4/8/24, the most current Healthcare Oversight the facility was able to provide during the on-site inspection was for the quarter ending 3/28/23.
Plan of Correction:	1. The Administrator has spoken with the Medical Director and expressed the need for residents to be seen more frequently. 2. The Medical Director has assigned a NP to the facility on a weekly basis. 3. The Administrator is currently exploring other providers for the resident care needs. 4. The Healthcare Oversight was performed on 01/17/2024. The next scheduled oversight is scheduled for 10/2024.
Standard #:	22VAC40-73-520-I
Description:	Based on observations made during a tour of the building, the facility failed to ensure the current month's activity schedule shall be posted in a conspicuous location in the facility. Evidence: 1. During the on-site inspection on 4/8/2024, the posted activities calendar was observed to be for February 2024. 2. Staff member #2 acknowledged there was no current activity schedule posted.
Plan of Correction:	1. The activity calendar is posted on the wall across from the nursing station. 2. Three-38 inches by 50 inches jumbo activities calendars have been ordered to display daily activities. 3. The next months calendar will always be prepared ahead of time in the event that any activities need to be changed.
Standard #:	22VAC40-73-610-B
Description:	Based on observation of facility postings, the facility failed to ensure that menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents. Evidence: 1. During the on-site inspection on 4/8/2024, there was no menu for the month posted. 2. Staff member # 1 acknowledged there was no menu posted.
Plan of Correction:	1. Menus for all three meals and snacks are posted outside the dining room doors upon entering the dining room. 2. Larger calendars have been ordered to go on the dining room door for residents to better see what is being served for each meal and snack.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review and review of the Medication Administration Record (MAR), the facility failed to have all items required by the Standards on the MAR. Evidence: 1. On 4/8/2024 during the on-site inspection, the licensing inspector observed Staff# 3 administering medication without having the MAR or copy of the physician?s orders for the medications being administered. 2. Staff members #2 and #3 acknowledged the computer system was not working properly and therefore the EMARs for the residents were not available.
Plan of Correction:	1.We have hired an LPN whose responsibility will be auditing and reviewing resident charts, physician orders, the MAR, and the medication cart supply. 2.Staff have been re-educated to correct policy and procedure on how to properly administer medication. 3.The pharmacy has been contacted to send a copy of all resident?s physician orders to facility for backup.