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: Sept. 11, 2024 and Sept. 26, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 09/26/24 3:00pm to 4:45pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 8/22/24 regarding allegations in the area(s) of: Staffing And Supervision and Resident Care And Related Services. Number of residents present at the facility at the beginning of the inspection: 72 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of residents, and activity was completed in the assisted living facility. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-H
Complaint related:	Yes
Description:	Based on a review of the medication administration records and interview, it was determined that the facility did not ensure that that the medication administration record (MAR) includes if the medication was administered or there was an omission. Evidence: 1. The Medication Administration Record (MAR) for Resident #1 did not indicate whether the medication was administered for multiple medications, dates and times. A. The MAR for Donepezil 10mg tab did not indicate whether the medication was administered, or it was not administered for the following dates and times: 8/1/24 (7:00pm), 8/3/24(7:00pm) 8/5/24(7:00pm), 8/6/24(7:00pm),8/7/24(7:00pm), 8/8/24(7:00pm), 8/9/24(7:00pm), 8/10/24(7:00pm), 8/11/24(7:00pm), 8/12/24(7:00pm), 8/13/24(7:00pm), 8/14/24(7:00pm), 8/15/24(7:00pm), 8/16/24(9:00pm), 8/17/24(7:00pm), 8/18/24(7:00pm), 8/20/24(7:00pm), 8/23/24, (7:00pm), 8/24/24 (7:00pm), 8/25/24(7:00pm), 8/26/24(7:00pm), 8/27/24(7:00pm). B. The MAR for Gabapentin 300mg cap did not indicate whether the medication was administered, or it was not administered for the following dates and times: 8/1/24 (7:00 pm), 8/3/24(7:00 pm) 8/5/24(7:00 pm), 8/6/24(7:00 pm), 8/7/24 (7:00pm), 8/8/24(7:00 pm), 8/9/24(7:00 pm), 8/10/24(7:00 pm), 8/11/24(7:00 pm),8/12/24(7:00 pm),8/13/24(7:00 pm),8/15/24(7:00 pm),8/16/24(7:00 pm),8/17/24(7:00 pm),8/18/24(7:00 pm),8/20/24(7:00 pm),8/23/24(7:00 pm),8/24/24(7:00 pm),8/25/24(7:00 pm),8/26/24(7:00 pm),8/27/24(7:00 pm),8/31/24(7:00 pm). C. The MAR for Propranolol 20mg tab did not indicate whether the medication was administered, or it was not administered for the following dates and times: 8/12/24(2:00pm). D. The MAR for Tramadol 50mg tab did not indicate whether the medication was administered, or it was not administered for the following dates and times: 8/1/24 (6:00 am, 10:00pm), 8/3/24(10:00pm) 8/5/24(10:00pm), 8/6/24(10:00pm), 8/7/24(10:00pm),8/8/24(10:00pm),8/9/24(10:00pm),8/10/24(10:00pm),8/11/24(10:00pm),8/12/24(2:00 pm,10:00pm), 8/13/24(10:00pm),8/14/24(10:00pm),8/15/24(10:00pm),8/16/24(10:00pm),8/17/24(10:00pm),8/18/24(6:00am,10:00pm),8/20/24(10:00pm),8/22/24(6:00 am, 10:00pm), 8/23/24 (10:00 pm), 8/24/24 (10:00 pm), 8/25/24 (10:00 pm), 8/26/24 (10:00 pm). 2. The Medication Administration Record (MAR) for Resident #2 did not indicate whether the medication was administered for multiple medications, dates and times. A. The MAR for Allergy Reli 10mg tab did not indicate whether the medication was administered, or it was not administered for the following dates and times: 8/6/24 (8:00am), 8/7/24 (8:00am), 8/25/24 (8:00am) B. The MAR for Lisinopril 10mg tab did not indicate whether the medication was administered, or it was not administered for the following dates and times: 8/6/24 (8:00am), 8/7/24 (8:00am), 8/25/24 (8:00am). C. The MAR for Memantine 10 mg tab did not indicate whether the medication was administered, or it was not administered for the following dates and times: 8/6/24 (8:00am), 8/7/24 (8:00am), 8/25/24 (8:00am). D. The MAR for Simvastatin 20mg tab did not indicate whether the medication was administered, or it was not administered for the following dates and times: 8/6/24 (8:00am), 8/7/24 (8:00am), 8/25/24 (8:00am). 3. The Medication Administration Record (MAR) for Resident #3 did not indicate whether the medication was administered for multiple medications, dates and times. A. The MAR for Atorvastatin did not indicate whether the medication was administered, or it was not administered for the following dates and times:8/3/24(7:00pm) 8/6/24(7:00pm), 8/8/24(7:00pm), 8/9/24(7:00pm),8/12/24(7:00pm),8/13/24(7:00pm),8/15/24(7:00pm),8/16/24(7:00pm),8/17/24(7:00pm),8/18/24(7:00pm), 8/20/24 (7:00pm), 8/22/24(7:00pm), 8/23/24(7:00pm), 8/26/24(7:00pm), 8/27/24(7:00pm) 4, Staff #5 confirmed the medication administration records for residents #1, #2, and #3 did not include notation if the medications were administered or if there was an omission.
Plan of Correction:	What Has Been Done to Correct? Documented Training of all Med Tech on procedures to document on EMAR and change of shift procedures. How Will Recurrence Be Prevented? Outgoing Med Tech will review omission report on EMAR at end of shift and correct any violations. Incoming Med Tech will report any EMAR omissions to direct supervisor at beginning of shift. Person Responsible: Executive Director, Resident Services Director, Medication Tech or Designee 10/15/24 Re-Training.