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 12, 2024

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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

22VAC40-73-690 22VAC40-73-980

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: 03/12/2024 from 8:45 am to 3:00 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: 53 Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast and an activity were observed. A medication pass observation was completed for 3 residents. The following were reviewed: resident and staff records, medication carts, and water temperatures. 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 #:	22VAC40-73-1030-B
Description:	Based on record review, the facility failed to ensure within four months of the starting date of employment, direct care staff attend six hours of training in working with individuals who have a cognitive impairment, and the training shall meet the requirements of subsection C of this section. Evidence: 1. Staff #1 was unable to provide evidence of the required six hours of training in working with individuals who have a cognitive impairment within four months of the starting date of employment for Staff #2 (hired 11/6/2023) and Staff #3 (hired 10/16/2023).
Plan of Correction:	1. Administrator will ensure that all staff members attend 6 hours of training in working with individuals who have a cognitive impairment within their first four months of work. 2. An audit of all staff members hired within the last 4 month was conducted to ensure all staff who have net met this requirement are assigned 6 hours of training in this area. 3. Current training plan will be revised with the appropriate corporate contact to ensure the training plan going forward meets the specified regulation. 4. An audit will be conducted on 3/31/2023 to ensure all staff have been brought current on appropriate education as it relates to residents? mental impairments.
Standard #:	22VAC40-73-100-C-2
Description:	Based on observation and interview, the facility failed to ensure when assisted blood glucose monitoring is required, fingerstick devices shall not be used for more than one person. Evidence: 1. During a review of the medication carts, unlabeled fingerstick devices were noted. 2. Staff #4 and Staff #5 verified fingerstick devices are utilized for more than one person.
Plan of Correction:	1. Resident Care Director will ensure that all residents have their own glucose monitor that is labelled with the resident?s name and stored individually. 2. An audit was then conducted to ensure each resident confirmed to require glucose monitoring had an individual glucose monitor. 3. Glucometers will be obtained for all residents who require them and staff will be educated on the proper use and storage of glucometers as well as the regulation requiring the use of separate monitors for each individual. 4. Audits will be conducted weekly X 4 weeks to ensure all residents have their own glucose monitor and they are on the medication carts and labelled accordingly.
Standard #:	22VAC40-73-210-F
Description:	Based on record review, the facility failed to ensure staff?s annual training include at least four hours of training focused on topics related to residents? mental impairments. Evidence: 1. Staff #4?s 2023 annual training did not include 4 hours of training focused on topics related to residents? mental impairments.
Plan of Correction:	1. Administrator will ensure that all staff who do not meet this requirement are assigned and complete 4 hours of training relating to residents? mental impairments. 2. An audit of all staff members education was conducted to ensure all staff who have net met this requirement are assigned 4 hours of training in this area. 3. Current training plan will be revised with the appropriate corporate contact to ensure the training plan going forward meets the specified regulation. 4. An audit will be conducted on 3/31/2023 to ensure all staff have been brought current on appropriate education as it relates to residents? mental impairments.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #2 (hired 11/6/2023) works as direct care staff and does not have a current certification in first aid.
Plan of Correction:	1. Resident Care Director will ensure all direct care staff members are current with First Aid Certification. 2. An audit was conducted of all direct care staff member First Aid certification to ensure that all staff are First Aid Certified. 3. First Aid classes will be scheduled and all direct care staff members who are missing the certification will be enrolled in and complete a First Aid course approved by the Virginia Department of Social Services. 4. An audit will be conducted weekly X 6 weeks of all direct care staff to ensure all staff obtain the First Aid certification.
Standard #:	22VAC40-73-410-A
Description:	Based on record review, the facility failed to ensure upon admission, the assisted living facility provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record. Evidence: 1. Resident #3 (admitted 5/15/2023) and Resident #5 (admitted 2/5/2024) did not have evidence of receiving orientation in their resident records.
Plan of Correction:	1. Administrator or designee will ensure all Resident?s who admit to the facility receive a proper orientation as outlined in the regulation and ensure proper documentation of the meeting is obtained. 2. An audit of all admission from the last 6 months was conducted to monitor for missing documentation as it relates to this requirement and missing documentation will be completed at the current time. 3. Education will be provided to the Marketing Director on the importance of completing and documenting a proper orientation with all new admissions. 4. An audit will be conducted weekly X 4 weeks of all new admissions to ensure that a proper orientation was documented and completed to prevent future deficient practice.
Standard #:	22VAC40-73-440-B
Description:	Based on record review, the facility failed to ensure the administrator or the administrator's designated representative approves and then signs the completed UAI for private pay individuals. Evidence: 1. The UAIs for Resident #1 (dated 12/8/2023), Resident #3 (dated 1/26/2024), Resident #4 (dated 1/18/2024), and Resident #5 (dated 1/31/2024) were not approved and signed by the administrator or the administrator?s designated representative.
Plan of Correction:	1. Administrator will ensure that all ISPs have the appropriate Administrator signature. 2. An audit of all UAIs was conducted and all missing signature lines were signed. 3. Education will be provided too all staff who are able to complete the UAI for private pay individuals on the requirement of Administrator Signatures being present on all private pay UAIs 4. An audit will be conducted weekly X 4 weeks on all Public Pay UAIs to ensure they have the Administrator?s Signature.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the comprehensive individualized service plan include a description of identified needs and the time frame for expected outcome. Evidence: 1. Resident #1?s UAI (dated 12/8/2023) indicates the resident is disoriented and requires physical assistance with bathing and dressing, bladder incontinence weekly or more, and assistance with money management and laundry; however, Resident #1?s ISP (dated 3/5/2024) does not address these needs. Resident #1?s ISP also does not include their allergies. 2. Resident #2?s UAI (dated 12/6/2023) indicates the resident requires physical assistance with toileting and assistance with medication administration; however, Resident #2?s ISP (dated 12/6/2023) does not address these needs. Resident #2?s ISP also does not include their code status. 3. Resident #3?s UAI (dated 1/26/2024) indicates the resident requires assistance with money management and laundry; however, Resident #3?s ISP (dated 2/9/2024) does not address these needs. Resident #3?s ISP also does not include their allergies. Additionally, Resident #3?s ISP indicates the resident requires mechanical assistance with bathing, toileting, and transfers; however, Resident #3?s UAI indicates the resident does not require assistance in these areas. 4. Resident #4?s UAI (dated 1/18/2024) indicates the resident requires physical assistance with toileting and wheeling and assistance with laundry, meal prep, and housekeeping; however, Resident #4?s ISP (dated 1/30/2024) does not address these needs. Resident #4?s ISP also does not include their code status. The ISP for Resident #4 does indicate the resident requires assistance with bathing, dressing, transferring, and incontinence; however, it does not indicate the type of assistance needed. 5. Resident #5?s ISP (dated 2/14/2024) states the resident requires mechanical and physical assistance with bathing and supervision with ambulation/mobility; however, Resident #5?s UAI (dated 1/31/2024) indicates the resident does not require assistance in these areas. 6. The ISPs for Resident #1 (dated 3/5/2024), Resident #2 (dated 12/6/2023), and Resident #4 (dated 1/30/2024) did not include the time frame for expected outcome.
Plan of Correction:	1. Resident Care Director or designee will ensure all identified needs be present on resident?s ISPs. 2. An audit of all ISPs was conducted to identify needs not present on the ISPs and will be corrected. 3. Education will be provided to all staff eligible to complete ISPs on how to properly complete an ISP and the information that must be present. 4. An audit will be conducted weekly X 4 weeks on all newly completed ISPs to ensure they are completed appropriately and accurately.
Standard #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure the individualized service plan be signed and dated by the resident or their legal representative. Evidence: 1. The ISPs for Resident #1 (dated 3/5/2024), Resident #2 (dated 12/6/2023), Resident #3 (dated 2/9/2024), Resident #4 (dated 1/30/2024), and Resident #5 (dated 2/14/2024) were not signed and dated by the resident or their legal representative.
Plan of Correction:	1. Administrator will ensure all that ISPs are signed by the resident and/or their legal representative upon completion of each new ISP. 2. An audit of all ISPs was conducted to identify ISPs that may be lacking appropriate signatures from either the Resident or their legal representative. All signatures will be obtained. 3. Education will be provided to all staff eligible to complete the ISP on obtaining proper signatures on all documents. 4. An audit will be conducted weekly X 4 weeks on all newly completed ISPs to ensure they are signed.
Standard #:	22VAC40-73-490-A
Description:	Based on interview, the facility failed to retain a licensed health care professional who has at least two years of experience as a health care professional in an adult residential facility, adult day care center, acute care facility, nursing home, or licensed home care or hospice organization, either by direct employment or on a contractual basis, to provide on-site health care oversight. Evidence: 1. Staff #1 was unable to provide a copy of a completed Health Care Oversight.
Plan of Correction:	1. Administrator will ensure that healthcare oversight is provided to all residents timely and in accordance with VDSS regulations. 2. An audit was conducted to compile a list of all residents who need healthcare oversight. All residents? healthcare oversight has been updated. 3. Education has been provided to the Administrator and RCD regarding the requirement of healthcare oversight. 4. Audits will be conducted monthly until all residents have a healthcare oversight.
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: Glipizide 5 mg tablets expired 2/24/2024 for Resident #7, PRN Meclizine 12.5 mg tablets expired 1/31/2024 for Resident #8, Pantoprazole Sodium 40 mg tablets expired 10/31/2023, Ferrous Sulfate 325 mg tablets expired 12/31/2023, and Magnesium Oxide 400 mg tablets expired 2/29/2024 for Resident #9, PRN Benzonatate 100 mg capsules expired 11/30/2023 for Resident #10.
Plan of Correction:	1. Resident Care Director will ensure that all staff members are compliant with the medication plan including policies to prevent the use of outdated medication and proper disposal of medications. 2. An audit was completed of both medication carts and any medications violating our medication management plan were removed. 3. Education will be provided to all staff who are certified to pass medications on the medication plan, including methods to prevent the use of outdated medication. 4. RCD will complete weekly audits X 6 to ensure the medication carts are free from expired medications and that medications are disposed of properly.
Standard #:	22VAC40-73-650-A
Description:	Based on record review and interview, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Evidence: 1. Staff #1 was unable to provide signed physician orders for the following medications: Ensure, Acetaminophen 500 mg tablets, Advanced Antacid, Ayr Nasal spray, Vitamin D 1250 mcg capsules, Desvenlafaxine 50 mg tablets, Esomeprazole Magnesium 40 mg capsules, Lamotrigine 150 mg tablets, Melatonin 10 mg capsules and Systane eye drops for Resident #1, Olmesartan 20 mg tablets and Aspirin 81 mg tablets for Resident #4, all active orders (18 total) for Resident #5, and Iron 325 mg tablets and Vitamin C 500 mg tablets for Resident #7.
Plan of Correction:	1. Resident Care Director will ensure that all medications, dietary supplements, diet, medical procedures, or treatments will have a valid order form a physician that is signed within 14 days if given verbally. 2. An audit was conducted of all orders to ensure all orders have a valid physicians signature. 3. Education will be provided to the RCD and all Nursing staff on obtained physicians signatures on verbal orders within 14 days. 4. RCD will audit all new orders weekly X 6 to ensure they have a physician?s signature within 14 days of the order.
Standard #:	22VAC40-73-680-C
Description:	Based on record review, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: 1. The following medications were scheduled, but not administration during the medication pass observation on 3/12/2024: Vitamin C, Milk of Magnesia, Omeprazole, Vitamin D3, and Methimazole for Resident #3 and Thera-M tablet for Resident #4. 2. Resident #3 has an order (dated 1/29/2024) to administer .5 of a Furosemide 20 mg tablet in the morning; however, it is not reflected on Resident #3?s MAR for administration.
Plan of Correction:	1. Resident care director will ensure that all medications are given within one hour before and one hour after the scheduled medication time. 2. An audit of the last 3 weeks of medication administration was complete. 3. All staff certified to pass medications will be educated on the medication administration policy as it relates to timeliness of medication administration times. 4. Resident Care Director will complete weekly audits X 6 to ensure compliance with medication administration times.
Standard #:	22VAC40-73-680-D
Description:	Based on observation and record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. Resident #1?s order for Trazodone 150 mg tablet reads to give .5 tablet by mouth in the evening; however, the MAR for Resident #1 indicates to administer 1 150mg tablet at bedtime. 2. Resident #1?s order for Vitamin D 1250 mcg capsule reads to give every 10 days; however, the MAR for Resident #1 indicates it is scheduled to be administered once a day on Mondays. 3. Resident #4 has two Carbidopa-Levodopa 25-100 mg orders which are to give 1.5 tablet by mouth 2 times a day and give 2 tablets by mouth 3 times a day; however, the MAR for Resident #4 indicates 1 order to administer 2 tablets every 4 hours. 4. Resident #4 has an order for PRN Acetaminophen that is not included on their MAR for administration. 5. The MAR indicates Resident #7?s Vitamin D3 is in capsule form; however, the resident was administered the medication in tablet form.
Plan of Correction:	1. Resident Care Director will ensure all orders for medication will match the medication administration record. 2. An audit of all orders was conducted on to ensure orders and medication administration records match. 3. Education will be provided to all nurses to ensure physicians orders and the medications administration match. 4. RCD will audit all conduct 5 medication administration pass observations weekly to ensure appropriate medication administration
Standard #:	22VAC40-73-680-I
Description:	Based on record review, the facility failed to ensure the MAR include a diagnosis, condition, or specific indications for administering the drug or supplement and dosage. Evidence: 1. The following medications did not have a diagnosis on the MAR: Advanced Antacid, Airsupra, Albuterol Sulfate, Aspirin 81 mg tablet, Bisacodyl 10 mg suppository, Desvenlafaxine 50 mg tablet, Esomeprazole Magnesium 40 mg capsule, Ensure, Lamotrigine 150 mg tablet, Letrozole 2.5 mg tablet, Linzess 145 mcg capsule, Magnesium Hydroxide, Myrbetriq 25 mg tablet, Risperdal .5 mg tablet (two separate orders), Rosuvastatin 20 mg tablet, Saline Nasal spray, and Tramadol 50 mg tablets for Resident #1, Aspirin 81 mg tablet, Vitamin C 500 mg tablet, Carvedilol 25mg table Klor-Con 20 mEq tablet, Lisinopril 10 mg tablet, Melatonin 5 mg tablet, Metformin 500 mg tablet, and Vitamin D3 25 mcg tablet for Resident #3, and Aspirin 81 mg tablets, Vitamin D3 50 mcg capsules, Crestor 20 mg tablets, Melatonin 5 mg tablets, Olmesartan 20 mg tablets, Omeprazole 20 mg capsules, Sinemet 25-100mg tablets, Theragran-M Premier 50 Plus Multi-Vitamin, and Rivastigmine patch for Resident #4. 2. Resident #1?s order for Melatonin is in the form of capsule; however, the MAR for Resident #1 documents Melatonin is in tablet form.
Plan of Correction:	1. Resident Care Director will ensure all medications include a diagnosis, condition, of specific indication on the medication administration record. 2. An audit was conducted of all resident?s MARs to ensure they include a diagnosis, condition, or specific indication. 3. All nursing staff will be educated on the need for a indication on all orders that are on the medication administration record. 4. RCD will audit all new orders weekly X 6 to ensure that all new orders have a proper indication on the medication administration record.
Standard #:	22VAC40-73-990-C
Description:	Based on interview, the facility failed to document staff participation in practice exercises for resident emergencies at least once every six months. Evidence: 1. Staff #1 was unable to provide documentation that staff had participated in an exercise in which the procedures for resident emergencies were practiced at least every six months.
Plan of Correction:	1. Administrator or designee will ensure that the facility practices and exercise for resident emergencies at least every 6 months. 2. An audit was conducted of resident emergency drills to ensure future compliance. 3. Education will be provided to the maintenance director about practicing emergency drills. 4. Monthly audits will be conducted to ensure future compliance with the practicing of emergency drills.