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: Feb. 18, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 The Sworn Statement or Affirmation

Comments:

An unannounced renewal inspection was conducted by two Licensing Inspectors (LI) from the Eastern Regional Office on 02-18-2022 from 8:12 AM to 2:23 PM. There were 47 residents in care at the time of the inspection. All of the required postings were in place, water temperatures were sampled and in range, and lunch meal observed. LI reviewed 3 staff records, 4 resident records, emergency supply, and conducted medication observations. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. The areas of noncompliance were discussed with the Administrator throughout the inspection and during the exit interview.

Violations:

Standard #:	22VAC40-73-260-C
Description:	Based on observation and interview, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR be posted in the facility so that the information is readily available to all staff at all times. Evidence: 1. Staff #1 confirmed and acknowledged a listing of all staff who have current certification in first aid or CPR is not posted in the facility.
Plan of Correction:	Current first aid and CPR certification status for staff added to posted schedule in the nurse?s station, location is available to all staff at all times. Resident Care Director (RCD) or designee will update status monthly.
Standard #:	22VAC40-73-320-B
Description:	Based on record review and interview, the facility failed to ensure a risk assessment for tuberculosis be completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. Two of the four resident records reviewed did not have an annual risk assessment for tuberculosis: Resident #2?s last risk assessment completed 10-23-2020 and Resident #3?s last risk assessment completed on 09-27-2020. 2. Staff #1 acknowledged the risk assessments for tuberculosis for Resident #2 and Resident #3 were not completed annually.
Plan of Correction:	Administrator or designee will ensure tuberculosis risk assessments for residents #2 and #3 are completed by RDCS. Administrator or designee will audit all residents to ensure all tuberculosis risk assessments are current.
Standard #:	22VAC40-73-440-A
Description:	Based on record review and interview, the facility failed to complete resident?s UAI at least annually. Evidence: 1. Two of the four resident records reviewed did not have an updated UAI: Resident #2?s last UAI completed 10-23-2020 and Resident #3?s last UAI completed on 09-27-2020. 2. Staff #1 acknowledged the UAIs for Resident #2 and Resident #3 were not completed at least annually.
Plan of Correction:	UAI for resident #2 and resident #3 update completed by administrator or designee. Administrator or designee will audit all residents for current UAIs and reassess any resident that is found to not have an UAI completed in the past 12 months.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the resident?s identified needs based on the Uniform Assessment Instrument (UAI). Evidence: 1. Resident #2?s ISP (dated 10/23/20) identifies a need for bladder incontinence weekly or more; however, the last UAI (dated 10/23/20) for Resident #2 states the resident does not require assistance with bladder incontinence. 2. Resident #3?s ISP (dated 9/27/20) does not address a need for assistance with eating/feeding; however, the UAI (dated 9/27/20) for Resident #3 states the resident requires physical assistance with eating/feeding. 3. Resident #4?s ISP (9/21/21) identifies a need for mechanical assistance with mobility via a wheelchair; however, the UAI (10/20/21) for Resident #4 states the resident does not require assistance with mobility.
Plan of Correction:	Resident #2?s UAI and ISP (updated on 2/23/2022) both reflect the need for bladder incontinence weekly or more. Resident #3?s UAI and ISP (updated on 2/22/2022) both reflect the need for assistance with eating/feeding. Resident #4?s UAI and ISP (updated on 2/23/2022) both reflect the need for mechanical assistance for mobility. Administrator or designee will audit all current resident?s UAI and ISP to ensure the required assistance is reflected on both the UAI and ISP.
Standard #:	22VAC40-73-450-F
Description:	Based on record review and interview, the facility failed to review and update resident?s individualized service plans at least once every 12 months. Evidence: 1. Two of the four resident records reviewed did not have an updated ISPs: Resident #2?s last ISP reviewed 10-23-2020 and Resident #3?s last ISP reviewed on 09-27-2020. 2. Staff #1 acknowledged the ISPs for Resident #2 and Resident #3 were not reviewed at least once every 12 months.
Plan of Correction:	ISP for resident #2 and resident #3 to be completed by the administrator or designee. The administrator or designee will audit all residents for current ISPs and update any resident that is found to not have an ISP completed in the past 12 months.
Standard #:	22VAC40-73-610-B
Description:	Based on observation and interview, the facility failed to post the menus for meals and snacks for the current week in an area conspicuous to residents. Evidence: 1. The breakfast and lunch menu for 02-18-2022 was observed to be posted in the dining room. 2. Staff #6 acknowledged the menus for meals and snacks for the current week are not posted in an area conspicuous to residents.
Plan of Correction:	Dining Services Director will post weekly menus that include the date and day of the week, are posted in the dining room for all residents to view as they please.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. On 12-09-2021, Resident #2?s order for PRN Acetaminophen was changed to every 8 hours as needed; however, Resident #2?s current MAR states for every 6 hours as needed and does not reflect the change. 2. Resident #1?s medication order for Norvasc 5mg Tablet included a parameter that states hold if SBP below 100 effective 2/15/22; however, there is no evidence that the resident?s blood pressure was taken on 2/15/22-2/18/22 and the resident was administered the medication. 3. Staff #1 and Staff #2 acknowledged the physician?s or other prescriber?s instructions on the aforementioned medications that were not reflected on the MAR and in administration.
Plan of Correction:	Resident #2?s order updated on MAR to reflect accurate order of Acetaminophen every 8 hours as needed. Resident #1?s order updated in electronic MAR to force documentation of blood pressure prior to administering Norvasc. Education for all LPN and Med Techs to check the returned signed physician order sheets for any changes that the primary care provider may have made. Education for all LPN?s to enter any order that contains parameters to force documentation of the parameter.
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to ensure the interior and exterior of all buildings be maintained in good repair and kept clean and free of rubbish. Evidence: 1. During a tour of the facility on 02-18-2022, two shower rooms and hall bathrooms were observed. In one shower room, the vents had a grey substance as well as broken tile in the shower. The other shower room observed had black substance on the vent and the overhead light was not operable. One of the hall bathrooms observed had the light cover missing over the sink and a black substance on the vent. The other hall bathroom observed also had grey, black substance on the vent, and the toilet was not operable. 2. Throughout the facility, brown stains were observed sporadically on ceiling tiles. 3. A broken window was observed covered with tape overlooking the contained courtyard.
Plan of Correction:	Maintenance Director or designee will repair broken tile in shower room and clean vents in all shower rooms and hall bathrooms. Missing light fixture cover will be replaced with new fixture and overhead light bulbs replaced. Inoperable toilet had been repaired but water line had not been turned back on, water line is on and toilet operating as expected. Maintenance Director or designee will perform weekly safety checks for all shower rooms and hall bathrooms. Maintenance Director or designee will replace all stained ceiling tiles. Maintenance Director or designee will do daily rounds of all hallways to observe for stained or damaged ceiling tiles. Maintenance Director or designee will coordinate to have cracked window pane replaced via company approved vendor.
Standard #:	22VAC40-73-980-B
Description:	Based on observation, the facility failed to ensure a first aid kit for the building and all vehicles being used to transport residents contain items as identified in the standard. Evidence: 1. A review of a first aid kit of the building and vehicle were reviewed. The building first aid kit did not include a blanket or triangular bandages. The vehicle first kit did not include triangular bandages or a first aid instructional manual.
Plan of Correction:	On day of inspection, administrator and life enrichment director did observe foil blanket in the building?s first aid kit and the vehicles first aid kit contained a cotton blanket. Building and vehicle?s first aid kits are supplied with a triangular bandage. First aid manual added to the vehicle?s first aid kit. Resident Care Director (RCD) and Life Enrichment Director or their designee will complete monthly checks of first aid kits utilizing check list that has all required supplies as well as check for expiration dates as applicable.
Standard #:	22VAC40-90-30-B
Description:	Based on record review and interview, the facility failed to ensure the sworn statement or affirmation be completed for all applicants for employment. Evidence: 1. Staff #5 (hired 01-24-2022) did not have a completed sworn statement in the record. 2. Staff #1 acknowledged Staff #5 did not have a completed sworn statement in the record at the time of inspection.
Plan of Correction:	Sworn statement for Staff #5 placed in employee file. HR coordinator educated that all staff, including transfers from a company facility, requires a sworn statement maintained in their employee file.