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: Dec. 22, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/22/2022 from 9:15 am to 10:10 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 12/10/2022 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: 47 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 Additional Comments/Discussion: All exit doors of the facility observed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-460-A
Description:	Based on discussion and record review, the facility failed to assume general responsibility for the health, safety, and well-being of the residents. Evidence: 1. On 12/10/2022 around 2:30 pm, Resident #1 was unable to be located. The resident was last seen in the facility by staff around 2:00 pm. The resident was found by local police around 5:00 pm behind the neighboring nursing center into a wooded area on the edge of a creek. The resident was transported and admitted to a local hospital. 2. Resident #1?s ISP acknowledges the resident wanders actively less than weekly. Additionally, based on the Elopement Risk Assessment, the intervention of a wander guard is in place for Resident #1 and checked for placement every shift.
Plan of Correction:	1. A facility incident and accident report was immediately completed. A 100% confirmation that all doors of egress were appropriately functioning was completed. Audible alarm identified as not turned on one exit door was activated and verified as functioning. Completed on 12/10/2022 2. All residents are potentially affected. Resident Care Director and/or designee to complete 100% reassessment of all resident?s elopement risk assessment has been completed. All appropriate changes to resident?s ISP?s and appropriate interventions were put in place for any resident newly identified as an elopement risk. Completed on 12/12/2022. 3. 100% in person education provided to all staff on elopement risks, signs, prevention, and protocol by Administrator and/or designee. 100% Education to dining staff to ensure kitchen door is closed when staff is not at steam table and review functioning of audible alarm in kitchen by Administrator. Completed on 12/13/2022. 4. Resident Care Director and/or designee will complete weekly elopement audit tool created to ensure compliance with risk assessment and monitor for changes in resident status. Audit will be forwarded to IDT team and reviewed during High Risk Meeting weekly. Completed on 12/16/2022.