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: April 9, 2024

Complaint Related: Yes

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 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 04/09/2024 from 12:10 p.m. to 4:48 p.m. A complaint was received by VDSS Division of Licensing on 03/22/2024 and 03/25/2024 regarding allegations in the area(s) of: Resident Care and Related Services, The Safe, Secure Environment, Buildings and Grounds, and Staffing and Supervision. 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: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: An observation of the safe, secure environment was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services, The Safe Secure Environment, and Buildings and Grounds. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 Donesia Peoples, Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1130-A
Complaint related:	Yes
Description:	Based on the onsite observation the facility failed to ensure except during night hours, when 20 or fewer resident are present, at least two direct care staff members shall be awake and on duty at all times in each special care unit who shall be responsible for the care and supervision of the residents. For every additional 10 residents, or portion thereof, at least one more direct care staff member shall be awake and on duty in the unit. Evidence: 1. During the onsite observation of the safe, secure unit on 04/09/2024, the Licensing Inspector (LI) observed only two direct care staff members (staff #1 and staff #2) working in the safe, secure unit at the time of 12:25 p.m. Staff #1 and staff #2 confirmed to be the only direct care staff working in the safe, secure unit during the shift of 7am -3pm. During the observation the facility had a recorded census of 24 residents residing in the safe, secure environment.
Plan of Correction:	What Has Been Done to Correct? Additional staff members have been hired How Will Recurrence Be Prevented? ED, RSD, or Designee will monitor to ensure adequate staffing. <20 Residents but >31 there will be three direct care staff members for Memory Care. The schedule will be reviewed daily to ensure regulatory compliance. Person Responsible: ED, RSD, or Designee
Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on the onsite record review the facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident?s condition. Evidence: 1. The record for resident #1, admitted 05/15/23, did not contain a UAI. Staff #4 was unable to provide documentation during the onsite inspection of a completed UAI for resident #1.
Plan of Correction:	What Has Been Done to Correct? Executive Director, Resident Services Director, & Resident Services Coordinator are Certified UAI Assessors and are now in place and available for all assessments. How Will Recurrence Be Prevented? ED, RSD, or Designee will review charts prior to resident admission, after admission, annually and whenever there is a significant change in condition to ensure regulatory compliance. Person Responsible: ED, RSD, or Designee
Standard #:	22VAC40-73-440-B
Complaint related:	No
Description:	Based on the record review the facility failed to ensure for private pay individual the UAI shall be completed by one of the qualified assessors: An assisted living facility staff person who has successfully completed state approved training on the UA1 and level of care criteria for either public or private pay assessments. Evidence: 1. The record for resident #2 contains a UAI that documents the assessment was completed by staff #3. The record for staff #3 did not contain verification staff #3 completed a state approved training on the UAI. Staff #4 was unable to provide documentation staff #3 completed a state approved training on the UAI.
Plan of Correction:	What Has Been Done to Correct? Executive Director, Resident Services Director, & Resident Services Coordinator are Certified UAI Assessors and are now in place and available for all assessments. How Will Recurrence Be Prevented? Only staff who have successfully completed the state approved UAI course will conduct the UAI?s to ensure regulatory compliance. Person Responsible: ED, RSD, or Designee
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian. Evidence: 1. Resident?s #1 ISP dated 09/14/23 was not signed and dated by the licensee, resident, or the legal guardian. 2. Resident?s # 2 ISP dated 03/14/24 was not signed and dated by the licensee, resident, or the legal guardian.
Plan of Correction:	What Has Been Done to Correct? Chart Audits are in progress How Will Recurrence Be Prevented? All current resident charts will be audited for compliance with regards to required signatures and dates to ensure regulatory compliance. Person Responsible: ED, RSD, or Designee
Standard #:	22VAC40-73-930-B
Complaint related:	Yes
Description:	Based on staff interviews the facility failed to ensure in buildings licensed to care for 20 or more residents under one roof, there shall be a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal. Evidence: 1. During an interview with staff #4 and staff #5, staff #4 and staff #5 confirmed in the month of March 2024 the signaling device/resident alert call system was not working in the assisted living, and safe, secure environment buildings. Staff #5 confirmed the signaling device/resident alert call system was not working the dates of 02/29/2024-03/25/2024.
Plan of Correction:	What Has Been Done to Correct? Signaling system has been serviced and upgraded. How Will Recurrence Be Prevented? Signaling system will be tested monthly/as needed by MD, ED, or Designee Person Responsible: ED, MD, or Designee