VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Devonshire
2220 Executive Drive
Hampton, VA 23666
(757) 827-7100

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: Feb. 17, 2023 , Feb. 22, 2023 and Feb. 28, 2023

Complaint Related: No

Areas Reviewed:

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 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Comments:

Type of inspection: Renewal An unannounced renewal inspection conducted on 2-17-23 (ar 07:00/dep 5:15 p.m.). Day 2 (ar 1:35 /dep 3:20 p.m). The facility census on day 1 was 29. A medication pass observation was conducted, a tour of the facility, breakfast meal observed, resident records reviewed, emergency preparedness and first aid kits/first aid cpr reviewed, staff records reviewed. Day 2: water temperatures, emergency food supplies and signaling checks. The Acknowledgement of Inspection form was signed and dated on both days of the inspection. 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 Willie Barnes Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-260-C
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the listing of all staff who have current certification in first aid (FA) and cardiopulmonary resuscitation (CPR) posted shall be kept up to date. Evidence: 1. On 2-17-23, the facility?s FA/CPR posting located in the nursing station room documented individuals with expired FA and CPR certifications. Staff #8, #9, and #10?s FA/CPR certification expired 11-5-22. 2. Staff #11?s CPR expired 10-16-22.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure in accordance with 63.2-1805- D of the Code of Virginia, it did not admit or retain individuals with any of the prohibited conditions or care needs for one of six residents. Evidence: 1. On 2-17-23, resident #4?s 1-5-23, physician visit notes documented resident prescribed Remeron, Sertraline, Xanax and Seroquel. The record also included a prescription for Lorazepam, 1-18-23. The record did not include a treatment plan for these psychotropic medications. 2. Staff #1 acknowledged the aforementioned resident?s record did not have a psychotropic treatment plan for all psychotropic medications.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-H
Description:	Based on record reviewed, the facility failed to ensure an annual reassessment and reassessment due to a significant change in the resident?s condition, using the uniform assessment instrument (UAI), shall be utilized to determine whether a resident?s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: 1. On 2-17-23, resident #5?s UAI in the record was dated 1-27-21 and 3-8-21 (completed by staff #1). The resident?s date of admission was noted as 1-31-21
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-K
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure for private pay individuals, the uniformed assessment instrument (UAI) shall be completed as required for one of eight records reviewed. Evidence: 1. On 2-17-23, resident #2?s uniformed assessment instrument (UAI) dated 11-1-22 was not signed and dated by an assessor or reviewer if the assessor was an employee of the facility. 2. Staff #1 acknowledged the aforementioned UAI was not completed as required.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 for four of six residents. Evidence: 1. On 1-17-23, resident #1?s hospital bed with bed rails were observed during the medication pass observation with staff #4. This need was not documented on the resident?s ISP dated 9-3-22. 2. Resident #2?s record documented physical therapy services (PT) dated 1-6-23, 1-9-23, 1-10-23, 12-23 and 1-15-23. Occupational therapy services (OT) services were dated from 12-29-22 to 1-19-23. The record included documentation of the occupational discharge dated 1-19-23. The physical examination dated 2-2-21 (signed by physician 3-15-21) documented resident?s allergy to Hydrocodone-acetaminophen. These needs were not documented on the resident?s ISP dated 11-9-22. 3. Resident #3?s physical examination dated 6-23-21 documented resident allergic to ASA and Doxycycline. These allergies were not documented on the resident?s 10-10-22 ISP. 4. Resident #6?s record documented physical therapy services 11-3-22 to 1-26-23. Occupational therapy services were dated 10-13-22- to 1-4-23. These services were not documented on the resident?s 11-20-22 ISP.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-650-B
Description:	Based on observation, record reviewed and staff interviewed, the facility failed to ensure physician or other prescriber orders, both written and oral, for administration of all prescription and over-the -counter medications and dietary supplements shall include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often the medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. On 2-17-23, during the medication pass observation with staff #4, resident #1?s February 2023 medication administration record (MAR) did not have a diagnosis for Clonazepam. The physician?s order sheet provided on 2-17-23 also did not have a diagnosis.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-710-B
Description:	Based on record review and staff interviewed the facility failed to ensure when physical restraint is used as a medical/orthopedic restraint for support a physician?s written order and the written consent of the resident or legal representative is obtained. Evidence: 1. On 2-17-23, a hospital bed with half-rail was observed in resident #1?s room. A review of the resident?s record did not include a written physician?s order and there was no written consent from the resident and/or legal representative in the record.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-860-G
Description:	Based on observation and staff interviewed, the facility failed to ensure the hot water at taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F. Evidence: 1. On 2-22-23, water temperature checks were conducted with staff #7. The temperature in room #153 was 128 degrees F and room #152 was 125.2 2. Staff #7 acknowledged the temperatures were more than 120-degree F. range.
Plan of Correction:	Not available online. Contact Inspector for more information.