VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Hamilton
113 Battle Road
Yorktown, VA 23692
(757) 898-1491

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: April 11, 2024 , April 16, 2024 and April 22, 2024

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 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 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: 04/11/2024 (arrival 10:00 am/departure 3:05 pm), 04/16/2024 (arrival 8:35 am/departure 2:45pm), 04/22/2024 (arrival 6:53am/departure 12:45pm). 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: 41 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: A tour of the facility was conducted. Breakfast, lunch, and an activity was observed. A medication pass observation conducted. The following was reviewed staff and resident records, emergency preparedness drills documents and supplies, health inspection report, fire inspection report. Water temperature was measured, and the call bell system monitored. Additional Comments/Discussion: None 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 #:	22VAC40-73-120-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure staff records included documentation of orientation and training required within the first seven working days of employment. Evidence: 1. On 04/11/2024 staff #6 record did not include documentation of orientation and training. Staff #6 date of hire was documented as 06/05/2023. 2. Staff #1 acknowledged the staff #6 record did not include documentation of required orientation and training.
Plan of Correction:	1. On 4/11/24 staff #6 record did not include documentation of orientation and training. Staff #6 date of hire was documented as 6/5/23. 2. The employee record was corrected on 5/15/2024. 3. Staff responsible for new hire orientation were re-educated on ensuring all new employees complete the ALF staff training within 7 days of hire. 4. The administrator/designee will perform weekly audits for 6 weeks on new employee records to ensure the ALF staff training is completed.
Standard #:	22VAC40-73-150-B-1
Description:	Based on staff interview, it was determined that the facility failed to notify the department?s regional licensing office in writing within 14 days of change in the facility?s administrator. Evidence: 1. The previous administrators last day of employment was on 03/14/2024. The facility notified the departments regional licensing office of the notification of change of administrator on 04/11/2024.
Plan of Correction:	1. The previous administrators last day of employment was on 03/14/2024. The facility notified the departments regional licensing office of the notification of change of administrator on 4/11/24. 2. This was corrected on 4/11/24. 3. VHS Corporate staff were educated on ensuring the regional licensing office is notified within 14 days when there is an administrator change.
Standard #:	22VAC40-73-260-C
Description:	Based on observation and staff interviewed, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR was kept current. Evidence: 1. On 04/11/2024, the first aid and CPR posting on the first floor at the nurse?s station was not kept current. The list included employees no longer employed with the facility and an employee with an expired first aid/CPR date of 09/19/2023. 2. Staff #1 acknowledged the posting was not current.
Plan of Correction:	1. On 4/11/24, the first aid and CPR posting on the first floor at the nurse?s station was not kept current. The list included employees no longer employed with the facility and an employee with an expired first aid/CPR date of 9/19/23. 2. The first aid and CPR posting at the nurse?s station was corrected on 4/11/24. The staff member has been enrolled in first aid and CPR and will be completed by 5/30/24. 3. The administrative assistant was educated on maintaining an up to date first aid and CPR listing posted at the nurse?s station. All nursing staff educated on needing to keep their first aid and/or CPR up to date as applies to their role. 4. The Administrator/designee will perform weekly audits for 6 weeks to ensure the first aid and CPR posting is kept up to date and staff members are current with their needed first aid and/or CPR.
Standard #:	22VAC40-73-550-G
Description:	Based on resident record review, the facility failed to ensure the rights and responsibilities of residents in assisted living shall be reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H. Evidence: 1. The following residents did not have current documentation of an annual review of resident rights and responsibilities: the record for resident #2 did not contain an annual review of resident rights and responsibilities, the record for resident #4 did not contain an annual review of rights and responsibilities completed after 07/19/2022, the record for resident #5 did not contain an annual review of rights and responsibilities completed after 11/28/2022, the record for resident #6 did not contain an annual review of rights and responsibilities completed after 07/31/2020, the record for resident #7 record did not contain an annual review of rights and responsibilities completed after 06/08/2022, and the record for resident #8 did not contain an annual review of rights and responsibilities completed after 12/02/2022.
Plan of Correction:	1. The following residents did not have current documentation of an annual review of resident rights and responsibilities: the record for resident #2 did not contain an annual review of resident rights and responsibilities, the record for resident #4 did not contain an annual review of rights and responsibilities completed after 07/19/2022, the record for resident #5 did not contain an annual review of rights and responsibilities completed after 11/28/2022, the record for resident #6 did not contain an annual review of rights and responsibilities completed after 07/31/2020, the record for resident #7 record did not contain an annual review of rights and responsibilities completed after 06/08/2022, and the record for resident #8 did not contain an annual review of rights and responsibilities completed after 12/02/2022. 2. Review of resident rights were completed on residents #2, #4, #5, and #7 on 5/15/24. Resident #6 is not a current resident. 3. Staff educated on ensuring residents rights are reviewed annually with residents. 4. The administrator/designee will audit resident records annually to ensure resident rights have been reviewed with the residents.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation the facility failed to ensure medication shall be stored in a manner consistent with the current standards of practice and the storage area shall be locked. Evidence: 1. On 04/11/2024, during the medication pass observation staff #4 went into resident #2?s room to administer medication and left the medication cart unattended and unlocked. 2. Staff #4 acknowledged the medication cart was left unattended and unlocked.
Plan of Correction:	1. On 04/11/2024, during the medication pass observation staff #4 went into resident #2?s room to administer medication and left the medication cart unattended and unlocked. 2. The medication cart was locked on 4/11/24. 3. RMA, LPNs, & RNs were re-educated on keeping the medication cart locked when it is not in direct sight. 4. The Resident Care Coordinator/designee will perform weekly med pass observations on 2 staff members for 6 weeks to ensure medication carts are being locked when not in direct sight.
Standard #:	22VAC40-73-970-A
Description:	Based on document review and staff interviewed the facility failed to ensure fire and emergency drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills requested for each shift in a quarter shall not be conducted in the same month. Evidence: 1. On 04/22/2024, the facility provided evidence of fire and emergency evacuation drills dated 01/31/2024 for first shift and 02/28/2024 for second shift. There was no evidence of the facility conducting fire and emergency evacuation drills for third shift for the first quarter of 2024. 2. Staff # 1 acknowledged the facility did not have documentation of a fire and emergency evacuation drill being conducted for third shift for the first quarter of 2024.
Plan of Correction:	1. On 4/22/24, the facility provided evidence of fire and emergency evacuation drills dates 1/31/24 for first shift and 2/28/24 for second shift. There was no evidence of the facility conducting fire and emergency evacuation drills for the third shift for the first quarter of 2024. 2. The third shift emergency and evacuation drill was performed on 4/19/24. 3. Staff responsible for conducting fire and emergency evacuation drills were re-educated on ensuring each shift is performed every quarter. 4. The administrator/designee will audit fire and emergency drill records monthly for the next 3 months to ensure they are being completed per reguolations.
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the first aid kit included all required items. Evidence: 1. On 04/11/2024, the first aid kit did not include the cold pack. 2. Staff #2 acknowledged the first aid kit did not include the cold pack.
Plan of Correction:	1. On 04/11/2024, the first aid kit did not include the cold pack. 2. The cold pack in the first aid kit was replaced on 4/11/24. 3. Nursing staff were re-educated on ensuring they replace any items removed from the first aid kit. 4. Director of Nursing/designee will perform weekly audits for 6 weeks to ensure all items are present in the first aid kit.