VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Chesapeake Place
1500 & 1508 Volvo Parkway
Chesapeake, VA 23320
(757) 548-0808

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: Feb. 11, 2022 , March 3, 2022 and March 17, 2022

Complaint Related: Yes

Areas Reviewed:

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 BUILDING AND GROUNDS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced complaint inspection was conducted on 2-11-22 regarding a complaint to the licensing office on 10-25-21, 12-10-21 and 1-20-22 regarding resident care and not being able to reach facility staff due to the telephone system not working on only able to leave a voice mail with the system. Resident records, staff and resident interviews were conducted regarding the allegation and the evidence gathered supported the allegations, therefore the complaint is "VALID". An exit meeting was conducted with the administrator on 2-11-22 and 3-17-22. The acknowledgement form was sent to the administrator electronically. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. POC due within 10 days.

Violations:

Standard #:	22VAC40-73-280-A
Complaint related:	Yes
Description:	Based on resident interviewed, documented reviewed, staff interviewed and observation, the facility failed to ensure it had staff adequate in knowledge, skills and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental and psychological well-being of each resident as determined by resident assessment and individualized service plan (ISP), and to ensure compliance with the regulation. Evidence: 1. The nursing schedule for medication aide and direct care staff for February 6, 2022 through February 12, 2022 did not include a staff to administer medication on the 3rd shift (11 p.m. to 7 a.m.). When the inspector arrived at 06:45 a.m., the 3rd shift direct care staffs, # 6 and #7 were present on the safe, secure unit with 21 residents. In the assisted living building next door, no medication aide could be located. Interviews with various residents stated there was no staff to give medications at night. Staff #3, registered medication aide, was observed coming down the hall and going toward the staff breakroom area of the building at approximately 07:05 a.m. Another registered medication entered the medication room approximately 07:20 a.m. 2. The facility have residents assessed as non-ambulatory requiring physical assistance to exit the assisted living building. There are residents who stated not being able to receive their prn pain medications at night due to no medication staff being available. One resident stated not receiving Synthyroid medication in the early morning and was voicing concern to the medication technicians on duty in the assisted living building on the morning of 2-11-22. 3. The schedule noted that the medication staff for the 11 p.m. to 7 a.m. is on-call. 4. Staff # 1 acknowledged on 2-11-22, staffing issues in the facility.
Plan of Correction:	ED and RSD will continue to solicited for third shift Med Tech/LPN. RSD will work with physician and pharmacy to ensure medications such as Synthyroid are provided on time as scheduled.
Standard #:	22VAC40-73-290-B
Complaint related:	Yes
Description:	Based on observation and staff interviewed, the facility failed to ensure the posting of current on-site person in charge, per the regulation, in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. On 2-11-21, at 06:45 a.m. the name of the staff person in charge posted with staff #1. This person was not on-site and did not arrive until after 08:00. The staff schedule did not indicate the staff person in charge at any given time. The schedule also noted the name in bold serve as the manager on duty. However, there was no multiple shifts with no name highlighted on the schedule. 2. The telephone to the facility does not ring to the staff person in charge and goes to a voicemail with a directory but not to the nursing station. The inspector call several times and did not receive a response on the early morning of 2-11-22. The inspector and staff #3 tried to determine why the phone was not ringing in the medication room. Several tries to dial the number provided, however, the phones in the medication room did not ring. 3. Staff #1 acknowledged, the staff person in charge information was not updated.
Plan of Correction:	ED will instruct supervisors to update MOD staff member at every shift change.
Standard #:	22VAC40-73-870-E
Complaint related:	Yes
Description:	Based on staff interviewed and observation, the facility failed to ensure all furnishings and equipment are in good repair. Evidence: 1 The telephone to the facility does not ring to the staff person in charge and goes to a voicemail with a directory but not to the nursing station. The inspector call several times and did not receive a response on the early morning of 2-11-22. The inspector and staff #3 tried to determine why the phone was not ringing in the medication room. Several tries to dial the number provided, however, the phones in the medication room did not ring. 2. Staff #1 acknowledged the telephone system was not working on the morning of 3-7-22 when the inspector arrived at the facility.
Plan of Correction:	Telephone service has been restored and phones are available at community 24/7. After hours, phones will be answered by care staff.