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: July 15, 2022 , July 21, 2022 and July 27, 2022

Complaint Related: No

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 EMERGENCY PREPAREDNESS 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal An unannounced renewal inspection was conducted by two inspectors (ERO and PLO) on 7-15-22, day one. (Ar 06:45/dep 17:10). Day 2 was conducted by one inspector on 7-21-22 (Ar 09:45/dep 13:30). The facility census on day 1 was 83. A medication pass observation was conducted, a tour of the facility was conducted, emergency preparedness items reviewed, signaling and water temperature observed. Staff and resident interviews and record reviews were conducted. The Acknowledgement of Inspection form was sent via email to the Administrator for both days of the inspection. The final exit meeting will be scheduled. 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 (Willie Barnes), Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-250-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a staff record included a copy of the sworn disclosure statement. Evidence: 1. On 7-15-22, staff #11?s record did not have documentation of a sworn disclosure statement. 2. On 7-15-22 and 7-27-22, staff #1 acknowledged the aforementioned staff did not have a signed sworn disclosure statement.
Plan of Correction:	? ED, BOM, or designee will ensure that staff members have a completed Sworn Disclosure Statement in their file prior to pulling their required background checks in order to remain compliant with the DSS Standard above. o Date to be completed Immediately and Ongoing as of 08-03-2022
Standard #:	22VAC40-73-260-C
Description:	Based on record reviewed and staff interviewed, the facility failed a listing of all staff who have current certification in first aid or CPR, shall be posted in the facility so that the information is readily available to all staff at all times. The listing must indicate by staff person whether the certification is in first aid or CPR or both and must be kept up to date. Evidence: 1. On 7-15-22 during a tour of the facility, the first aid or CPR listing was not posted and was not updated. The listing dated 4-14-2022 included the names of eight staff members with expired first aid and CPR dates ranging from 1-22-2021 through 3-31-2022. 2. On 7-15-22 and 7-21-17 staff #1 and # 3 acknowledged the facility?s first aide/CPR listing was not posted and not updated.
Plan of Correction:	? ED, BOM, or designee will ensure that CPR & First Aide Current Staff list is posted in both buildings and maintained current. Will be updated with change in staff and/or at least monthly. ? Updated list was posted in both buildings on 07-27-2022. o Date to be completed Immediately and Ongoing as of 08-03-2022
Standard #:	22VAC40-73-280-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it had staff adequate in knowledge, skills and abilities and sufficient in numbers to provided services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with the regulation. Evidence: 1. On 7-15-22, the staff scheduled provided for the nursing department for the assisted living and the memory care did not have a medication staff on duty for the 3rd shift (11 p to 7a) on the following dates: 7-1-22; 7-4-22; 7-10-22; 7-15-22; 7-18-22 and 7-23-22. 2. On 7-27-22, staff #1 acknowledged the staffing schedule did not have a medication administration staff on duty on the aforementioned dates.
Plan of Correction:	? ED, RSD, or designee will ensure that a Medication Aide is on duty for each shift. o Date to be completed: Immediately and Ongoing as of 07-27-2022. RCC has covered 11p ? 7a as needed to ensure compliance as of 07-27-2022.
Standard #:	22VAC40-73-320-A
Description:	Based on record reviewed and staff interview, the facility failed to ensure a resident?s record included the results of a risk assessment documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. On 7-15-22, resident #2?s record did not have documentation of the results of a risk assessment documenting the absence of tuberculosis prior to admission. The resident?s date of admission was documented as 1-4-22. 2. On 7-15-22 and 7-27-22, staff #1 acknowledged the aforementioned resident?s record did not include a risk assessment.
Plan of Correction:	? ED, RSD, or designee will ensure that all residents have an TB risk assessment performed by an appropriate provider and that this assessment is placed in their file prior to admission. o Date to be completed Immediately and Ongoing as of 07-30-2022
Standard #:	22VAC40-73-440-D
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the uniformed assessment instrument (UAI) for private pay individuals, in an assisted living facility was completed as required. Evidence: 1. On 7-15-22, resident #3?s uniformed assessment instrument (UAI) dated 1-28-22 was not signed by the administrator or another designee. 2. On 7-21-22, resident #5?s UAI dated 3-29-22 was not signed by the administrator or another designee. 3. On 7-21-22, staff #1 acknowledged the aforementioned residents? UAI did not include all required signatures.
Plan of Correction:	? ED, RSD, RSC or designee will ensure that all UAI?s are signed by two designees to remain in compliance with the appropriate DSS Standard. The ED, RSD, RSC or designee will review at minimum 5 charts weekly to ensure that all UAI?s have dual signatures by appropriate designees. o Date to be completed Immediately and Ongoing as of 08-03-2022
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the comprehensive individualized service plan (ISP) was completed within 30 days and included all assessed needs for a resident. Evidence: 1. On 7-15-22, resident 3?s record did not include an individualized service plan (ISP). The resident?s date of admission was documented as 2-3-22. 2. On 7-21-22, resident #5?s ISP dated 5-10-22 did not include the resident?s physical therapy and occupational therapy services. The resident?s UAI dated 3-29-22 documented stairclimbing not performed. The ISP documented stairclimbing need as- human help and handrail assistance. 3. On 7-17-21, resident #6?s record included a Do Not Resuscitate (DNR) document signed by a physician and dated 6-20-22. The ISP dated 6-17-22 documented the resident as a ?Full Code?. The social data also documented resident as ?Full Code?. 4. On 7-21-22 staff #1 acknowledged the aforementioned residents? record did not include an ISP and other resident?s record did not include all assessed needs on the ISP.
Plan of Correction:	? ED, RSD, RSC or designee will ensure that all ISP?s are completed within 30 days of admission and include an assessment of all the current needs and services provided to the resident both by community representatives and additional therapy agents. ED, RSD, and RSC or designee will also ensure that the appropriate end of life wishes are documented appropriately on the ISP. ? ED, RSD, RSC or designee will review at minimum 5 charts weekly to ensure that all ISP?s are documented correctly to include all required information. o Date to be completed Immediately and Ongoing as of 07-30-2022
Standard #:	22VAC40-73-450-D
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP). Evidence: 1. On 7-15-22, resident #4?s record documented resident receives hospice care services from a local agency. The services provided were not document on the ISP dated 7-1-21. 2. On 7-15-22 and 7-27-22, staff #1 acknowledged, the aforementioned residents? ISP did not include what services were provided and when services would be provided.
Plan of Correction:	? ED, RSD, RSC or designee will ensure that if Hospice care is provided to a resident that the ISP for said resident reflects the services provided by the Hospice Company. ED, RSD, RSC or designee will communicate with Hospice agency to ensure that open communication between community and Hospice Company is reflective to any changes, and said changes in care can be updated in ISP. o Date to be completed Immediately and Ongoing as of 07-30-2022
Standard #:	22VAC40-73-450-E
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the license, administrator, or his designee, (i.e. the person who has developed the plan), and by the resident or his legal representative. These requirements shall also apply to reviews and updates of the plan. Evidence: 1. On 7-15-22, resident #2?s ISP dated 2-5-22 was not signed and dated by the resident and/or the resident?s legal representative. 2. On 7-15-22 and 7-27-22, staff #1 acknowledged the aforementioned resident?s ISP was not sign and dated by the resident and/or resident?s legal representative.
Plan of Correction:	? ED, RSD, RSC or designee will ensure that all ISP?s are signed by two designees to remain in compliance with the appropriate DSS Standard. The ED, RSD, RSC or designee will review at minimum 5 charts weekly to ensure that all ISP?s have dual signatures by appropriate designees. o Date to be completed Immediately and Ongoing as of 08-03-2022
Standard #:	22VAC40-73-710-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure physical restraints was only used as a medical/orthopedic restraint for support, according to a physician?s written order and with the written consent of the resident or the legal representative. Evidence: 1. On 7-21-22, resident #5?s individualized service plan (ISP) dated 5-10-22 documented resident bed contained half rails and was used for turning/positioning. The record did not include a physician?s order for the use of the bed rails for support. 2. On 7-21-22, staff #1 and #2 acknowledged the aforementioned resident?s record did not have a physician?s order for the side rails for support/positioning.
Plan of Correction:	? ED, RSD, RSC or designee will ensure that all physical restraints including bedrails that are utilized for positioning or support are accompanied into the community with a written physicians order in addition to written consent of the resident or their POA. o Date to be completed Immediately and Ongoing as of 07-30-2022
Standard #:	22VAC40-73-970-E
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure the fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code. The drills required for each shift in a quarter shall not be conducted in the same month. Evidence: 1. On 7-21-22, the facility fire drills document for 5-23-22 was documented to have been completed on the 3rd shift. The fire drill for 6-6-22 was completed on the 3rd shift. The fire drill for 7-14-22 was completed on the 1st shift. 2. The fire drill documents did not include the any special conditions simulated and the weather conditions. 3. On 7-21-22, staff #1 acknowledged the fire drills for the facility was not conducted as required and did not include all required information.
Plan of Correction:	? ED, MD, or designee will ensure that Fire drills will be conducted on a rotating shift basis every quarter. They will not be conducted on the same shift during the same quarter. o Date to be completed Immediately and Ongoing as of 08-01-2022
Standard #:	22VAC40-90-40-B
Description:	Based on the employee record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee. Evidence: 1. On 7-15-22, staff 5?s record did not have documentation of a criminal record report within 30 days of the date of hire. Staff?s date hire was documented as 5-14-22. 2. Staff #10?s record did not have documentation of a criminal record report. Staff?s date of hire was documented as 4-19-22. 3. Staff #12?s criminal record report was dated 1-5-22. Staff?s date of hire was documented as 11-9-21. 4. On 7-15-21 and 7-27-22 staff #1 acknowledged the aforementioned staffs criminal record report was not obtained within the required 30 days of hire.
Plan of Correction:	? ED, BOM, or designee will ensure that the prior to employment the DSS required background check will be present in their files to ensure that the candidates are cleared for employment in Senior Living. o Date to be completed Immediately and Ongoing as of 07-30-2022