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: March 7, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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

Comments:

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: 03/07/2023 from 8:30 am to 3:45 pm. 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: 48 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of interviews conducted with staff: 4 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-325-A
Description:	Based on record review, the facility failed to ensure for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating be completed. Evidence: 1. Upon review of the resident?s record, Resident #5 meets the criteria for assisted living care; however, there is no documentation of a fall risk rating being completed in the resident?s record.
Plan of Correction:	Resident #5 fall risk rating has been completed. A 100% audit of all residents? medical records has been completed to ensure that fall risk ratings are current and accurate in each record. 100% Education for all licensed nurses by RCD on fall risk rating procedure and requirements and completion requirements. Resident Care Director (RCD) or designee will audit charts of all new residents within the first 72 hours for completeness, accuracy, and interventions of fall risk ratings for the next 3 months. All findings will be forwarded to the community IDT
Standard #:	22VAC40-73-325-B
Description:	Based on record review, the facility failed to ensure a fall risk rating is completed at least annually, when the condition of the resident changes, and after a fall. Evidence: 1. Upon review of the resident?s record, Resident #1 fell on 9/29/2022; however, there is no documentation of a fall risk rating being completed after the fall in the resident?s record. 2. Upon review of the resident?s record, the last annual fall risk rating for the Resident #2 was completed 06/10/2021. 3. Upon review of the resident?s record, Resident #3 fell on 9/17/2022; however, there is no documentation of a fall risk rating being completed after the fall in the resident?s record.
Plan of Correction:	Resident #1, #2, and #3 have had fall risk rating completed. A 100% audit of all residents? medical records has been completed to ensure that fall risk ratings are current and accurate in each record. 100% Education for all licensed nurses by RCD on fall risk rating procedure and requirements and completion requirements. Resident Care Director (RCD) or designee will audit charts of all new resident each month to ensure annual fall risk rating is completed. RCD or designee will audit all charts of residents reviewed at weekly high risk meeting with fall to ensure fall risk rating post fall has been completed. RCD will complete audits for next 3 months. All findings will be forwarded to the community IDT team.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication. Evidence: 1. The following expired medications were observed in the medication carts at the facility: two bottles of Linzess 145 mcg capsules expired 11/2022 for Resident #8, Glipizide 2.5 mg tablets expired 2/25/23 for Resident #9, Januvia 50 mg tablets expired 2/14/23 and 2 packs of Xifaxan 550 mg tablets expired 11/30/22 and 2/25/23 for Resident #10, Donepezil 10 mg tablets expired 2/25/23 and Vitamin D-3 2000-unit tablets expired 2/25/23 for Resident #11, and Losartan 50 mg tablets expired 10/31/22 and two bottles of Bumetanide 2 mg tablets expired 10/7/22 and 2/19/23 for Resident #12. 2. The following medications of discharged residents were observed in the medication carts at the facility: Orgovyx 120 mg tablets and Mirtrazapine 30 mg tablets for Resident #6, Lorazepam .5 mg tablets, Tramadol 50 mg tablets, Loperamide 2 mg capsules for Resident #13, and Ondansetron 4 mg tablets for Resident #14.
Plan of Correction:	The two bottles of Linzess 145 mcg capsules expired 11/2022 for Resident #8, Glipizide 2.5 mg tablets expired 2/25/23 for Resident #9, Januvia 50 mg tablets expired 2/14/23 and 2 packs of Xifaxan 550 mg tablets expired 11/30/22 and 2/25/23 for Resident #10, Donepezil 10 mg tablets expired 2/25/23 and Vitamin D-3 2000-unit tablets expired 2/25/23 for Resident #11, and Losartan 50 mg tablets expired 10/31/22 and two bottles of Bumetanide 2 mg tablets expired 10/7/22 and 2/19/23 for Resident #12 were immediately removed from the medication cart and destroyed. The following medications of discharged residents were observed in the medication carts at the facility: Orgovyx 120 mg tablets and Mirtrazapine 30 mg tablets for Resident #6, Lorazepam .5 mg tablets, Tramadol 50 mg tablets, Loperamide 2 mg capsules for Resident #13, and Ondansetron 4 mg tablets for Resident #14 were immediately removed from the medication cart. A 100% Medication Carts audit was completed on all medication carts to ensure no discharged residents medications or expired medications were on the cart. All discontinued medications and discharged resident?s medications have been removed from carts and properly disposed. 100% Education to all licensed nursing and medication technicians on the Rights of Medication Administration and the Facility Medication storage policy and procedure. RCD or designee will audit medication carts weekly for 3 months. All audits will be forwarded to the IDT Team.
Standard #:	22VAC40-73-650-C
Description:	Based on record review, the facility failed to ensure physician's or other prescriber's oral orders are reviewed and signed by a physician or other prescriber within 14 days. Evidence: 1. Resident #3 has a verbal order for Melatonin 3mg tablet (ordered 11/6/2022); however, there is not an order signed by a physician or other prescriber within 14 days in the resident?s record. 2. The following are verbal physician orders for Resident #4: PRN oxygen (ordered 12/19/2022), Mylanta Suspension 200-200-20 MG/5ml (ordered 12/6/2022), and Omeprazole 40 mg capsule (ordered 12/6/2022). There were no signed orders for these medications by a physician or other prescriber within 14 days in the resident?s record. 3. The following are verbal physician orders for Resident #5: Citalopram Hydrobromide 40 mg tablet (ordered 9/12/2022), Imodium A-D 2mg capsule (ordered 1/9/2023), Mylanta Suspension 200-200-20 MG/5ml (ordered 9/12/2022), and Prilosec 20mg tablet. There were no signed orders for these medications by a physician or other prescriber within 14 days in the resident?s record.
Plan of Correction:	Medication orders for residents #3, 4, and 5 signed by physician on 3/7/2023. 100% Education of all licensed nurses and Med Techs by RCD on the facility policy and procedure or physician order?s and active physician order summaries was completed. RCD or designee will audit complete weekly audit to ensure all verbal orders are signed timely, and all physician order summaries are signed monthly by the resident?s primary care physician. All audit findings will be forwarded to the IDT team.
Standard #:	22VAC40-73-690-G
Description:	Based on interview and record review, the facility failed to act in response to the recommendations noted in subsection F of this section. Evidence: 1. Upon record review and interview, a pharmacy medication review was conducted on 1/16/2023. Two of the six resident records reviewed included medication recommendations for physician review and response; however, there was no documentation that the recommendations were sent for physician review and response at the time of inspection.
Plan of Correction:	The pharmacy recommendations from last completed pharmacy review in inspection sample were sent to physician for review. 100% of all pharmacy recommendations from the last 6 months were faxed to providers on 3/8/2023. RCD or designee to ensure all physician determinations regarding pharmacy review will be appropriately addressed upon receipt. RCD to receive education regarding the community?s procedure for pharmacy recommendations from the Regional Director of Clinical Services. RCD and/or designee will conduct 100% pharmacy recommendation audits monthly. All results of findings will be reviewed by the IDT team monthly.
Standard #:	22VAC40-73-950-F
Description:	Based on interview, the facility failed to review the emergency preparedness plan annually or more often as needed, documenting the review by signing and dating the plan, and making necessary plan revisions. Such revisions should be communicated to staff, residents, and volunteers and incorporated into the orientation and semi-annual review for staff, residents, and volunteers. Evidence: 1. Staff #1 could not provide documentation of an annual review of the emergency preparedness and response plan.
Plan of Correction:	The Facility Administrator and Maintenance Director will develop an Emergency Preparedness and Response Plan for the community. Regional Vice President of Operations will educate the Administrator and IDT team on Emergency Preparedness and Response Plan. Emergency preparedness plan reviewed and annual sign off sheet completed. Administrator will ensure annual review completed and signed of yearly. The plan will be forwarded to the IDT team.
Standard #:	22VAC40-90-30-B
Description:	Based on record review, the facility failed to ensure a sworn statement or affirmation be completed for all applicants for employment. Evidence: 1. The following sworn disclosure statements were not properly completed: Staff #3, Staff #5, Staff #6, Staff #7, Staff #8, and Staff #9.
Plan of Correction:	Sworn Disclosure Statements for Staff #3, Staff #5, Staff #6, Staff #7, Staff #8, and Staff #9 have been completed appropriately and all background checks have been rerun through the Virginia State Police database. A 100% audit of all staff files to be done to ensure completeness and accuracy of all sworn disclosure statements. The Facility Administrator will educate the Human Resources and Payroll Manager on ensuring accuracy of sworn disclosure statements for any new hire personnel. Facility Administrator to audit any new hire personnel weekly for the next 3 months to ensure completeness and accuracy of sworn disclosure statements.