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: Sept. 28, 2023 and Oct. 4, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 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: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/28/2023. 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 09/27/2023 regarding allegations in the area(s) of: Personnel. Number of residents present at the facility at the beginning of the inspection: 54 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 staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Additional Comments/Discussion: LI followed up on a self-reported incident. 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 #:	22VAC40-73-40-B-12
Description:	Based on interview, the facility failed to ensure that at all times the department's representative is afforded reasonable opportunity to inspect all of the facility's buildings, books, and records and to interview agents, employees, residents, and any person under its custody, control, direction, or supervision as specified in ? 63.2-1706 of the Code of Virginia. Evidence: 1. Staff #2?s record was requested for review at 1:30 pm upon entry into the facility and was unavailable for review at 3:15 pm upon licensing departure.
Plan of Correction:	Facility completed an audit of all files and will be transitioning employee files online so that they can be more accessible when surveyors enter the building. This file change will be completed by December 15th, 2023 to ensure employee files are more easily attainable when requested.
Standard #:	22VAC40-73-250-C
Description:	Based on record review, the facility failed to ensure personal and social data be maintained on staff and included in the staff record. Evidence: 1. Staff #2?s record does not include verification that the staff person has received a copy of their current job description.
Plan of Correction:	All HR files will be audited to ensure signed job descriptions are included in everyone?s file. Any employee who is missing a signed job description will be presented with a current job description and an acknowledgement will be obtained to ensure all staff members are aware of assigned job duties.