VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Villages of Rosemont
3751 Sentara Way
Virginia beach, VA 23452
(757) 901-1550

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: April 5, 2021 and April 6, 2021

Complaint Related: No

Areas Reviewed:

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 4/5/21 and concluded on 4/6/21. The Administrator was contacted to initiate the inspection. The Administrator reported that the current census was 45. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, staff schedules, fire and emergency evacuation drills, and Health Care Oversight submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-970-A
Description:	Based on record review and discussion the facility failed to conduct fire and emergency evacuation drills as required during each shift in a quarter. Evidence: 1. Fire and emergency evacuation drills were conducted and dated 1/29/21 at 10am (7am-3pm 1st shirt); 2/28/21 at 6:55pm (3pm-11am 2nd shift); and 3/23/21 at 1pm (7am-3pm 1st shift). 2. During January ?March 2021 (first quarter); no fire and emergency evacuation drill was conducted on the 11pm-7am third shift. 3. Staff #4 acknowledged there was no fire and emergency evacuation drill conducted on the 11pm-7am third shift for the first quarter.
Plan of Correction:	Maintenance director educated on regulation requirements and will ensure fire and emergency evacuation drill are conducted on each shifts at least once a quarter. Fire and emergency evacuation drill will be conducted on 11pm-7am third shift in April 2021. Administrator or designee will audit fire and emergency evacuation log weekly to ensure compliance.