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 and April 16, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 4/8/2024 and 4/16/2024 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 2/23/2024 regarding allegations in the area(s) of: Resident Care and Related Services 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: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-310-H
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without a treatment plan. Evidence: Resident #1 was prescribed Risperdone 2 mg, and Trazodone 50mg. The resident?s file did not contain psychotropic treatment plans for the prescribed medications.
Plan of Correction:	1. Counseling and re-education were provided to the staff members responsible for placing existing treatment plans in every resident chart that is on psychotropic medication. Any new residents entering the facility on psychotropic medication will have a treatment plan placed in their chart. 2. A new process has been developed, implemented whereas all residents? charts have been audited and psychotropic treatment plans have been placed in each resident?s chart.
Standard #:	22VAC40-73-680-B
Complaint related:	No
Description:	Based on observation and staff interview, the facility failed to ensure medication shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. Evidence: On 4/08/2024, during an on-site observation of the medication pass with Staff #1, the licensing inspection observed pre-poured medications for 2 residents in the top drawer of the medication cart.
Plan of Correction:	1. Re-education for all Certified Medication Aides on the medication management policy. They have been re-educated those medications are not to be pre-poured under any circumstance, And, 1. Re-education for all Certified Medication Aides on the medication management policy. They have been re-educated those medications are not to be pre-poured under any circumstance, And, that all medications are to remain in the pharmacy packaging until administering medication to the prescribed resident. The medication administration has been reviewed with each Medication-Aide and signed by each Medication Aide stating that they understand the policy. Any Medication Aide found pre-pouring medication going forward will be suspended for three days without pay and a second offense will result in termination. 2. The Administrator and Unit Coordinator will routinely make unannounced cart inspections to observe the Med-Techs to look for any pre-poured medications in the carts. 3. If, any pre-poured medications are found the Med-Tech will be subject to disciplinary actions.