VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Living Well Assisted Living
2600 Shorehaven Drive
Virginia beach, VA 23454
(757) 690-2744

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: Dec. 29, 2022

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:

22VAC40-73-560

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/29/2022 from 9:00 am to 4:00 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: 4 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: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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 #:	22VAC40-73-50-B
Description:	Based on record review and interview, the facility failed to obtain written acknowledgment of the receipt of the disclosure by the resident or their legal representative. Evidence: 1. During the onsite inspection on 12/29/2022, Resident #4 (admitted 12/02/2022) did not have written acknowledgement of the receipt of the disclosure statement by the resident or their legal representative in their resident record. 2. During the onsite inspection on 12/29/2022, Staff #4 acknowledged Resident #4 did not have written acknowledgement of receiving the facility?s disclosure statement in their resident record.
Plan of Correction:	Resident #4 disclosure statement receipt was placed in the residents file. The files for all other residents were checked to ensure compliance. Administrator or designee will check the resident file at time of admission to ensure compliance. Administrator or designee will review a minimum of 3 resident files per month to ensure ongoing compliance.
Standard #:	22VAC40-73-310-D
Description:	Based on record review, the facility failed to provide written assurance to a resident or the legal representative documenting that the facility has the appropriate license to meet their care needs upon receiving licensure. Evidence: 1. During the onsite inspection on 12/29/2022, there was no evidence of written assurance to Resident #2, Resident #3 or their legal representatives documenting that the facility has the appropriate license to meet their care needs upon receiving licensure.
Plan of Correction:	Resident #2 and 3 written assurance was placed in the residents file. The files for all other residents were checked to ensure compliance. Administrator or designee will check the resident file at time of admission to ensure compliance. Administrator or designee will review a minimum of 3 resident files per month to ensure ongoing compliance.
Standard #:	22VAC40-73-330-A
Description:	Based on record review and interview, the facility failed to ensure a mental health screening be conducted prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual. Evidence: 1. Resident #4 admitted to the facility on 12/02/2022. A progress note dated 12/06/2022 indicates resident is diagnosed with advanced dementia, was physically aggressive with a family member, and admitted to an ALF due to the inability to manage the resident in the home setting. 2. During the onsite inspection on 12/29/2022, Staff #4 acknowledged Resident #4 did not have a mental health screen completed in their resident record.
Plan of Correction:	Resident #4 mental health screening was added to resident chart. The files for all other residents were checked to ensure compliance. Administrator or designee will check the resident file at time of admission to ensure compliance. Administrator or designee will review a minimum of 3 resident files per month to ensure ongoing compliance.
Standard #:	22VAC40-73-350-B
Description:	Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the date the information was obtained. Evidence: 1. During the onsite inspection on 12/29/2022, Resident #2 did not have a completed sex offender screening in their record.
Plan of Correction:	Resident #2 sex offender screening was placed in the residents file. The files for all other residents were checked to ensure compliance. Administrator or designee will check the resident file at time of admission to ensure compliance. Administrator or designee will review a minimum of 3 resident files per month to ensure ongoing compliance.
Standard #:	22VAC40-73-410-A
Description:	Based on record review, the facility failed to ensure upon receiving licensure and 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. During the onsite inspection on 12/29/2022, Resident #1 (admitted 11/26/2022) and Resident #3 did not have evidence of receiving orientation.
Plan of Correction:	Resident #1 documentation of orientation was placed in the residents file. The files for all other residents were checked to ensure compliance. Administrator or designee will check the resident file at time of admission to ensure compliance. Administrator or designee will review a minimum of 3 resident files per month to ensure ongoing compliance.
Standard #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure the individualized service plan is signed and dated by the resident or their legal representative. Evidence: 1. During the onsite inspection on 12/29/2022, Staff #4 was unable to provide documentation indicating Resident #1, Resident #2, Resident #3, or Resident #4 have signed and dated their individualized service plan.
Plan of Correction:	Signatures were obtained for the ISP for Resident #1-4. ISPs for all other residents were checked to ensure compliance. Administrator or designee will check the resident file at time of admission to ensure compliance. Administrator or designee will review a minimum of 3 resident files per month to ensure ongoing compliance.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to implement their written plan for medication management to include methods to prevent the use of outdated medications. Evidence: 1. A expired medication, Pantoprazole Sod DR 40 mg tablets expired 03/2022, for Resident #2 was observed in the medication cart for administration.
Plan of Correction:	Prescriber and responsible party for resident #2 were notified and the resident had no adverse effects. All other medication and treatments were inspected with no additional concerns. All nurses and RMAs were re-educated on the medication management policy and to specifically dispose of any expired medications and do not administer.
Standard #:	22VAC40-73-650-A
Description:	Based on record review and discussion, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications. Evidence: 1. Staff #5 was unable to provide the physician?s order for Mucinex Fast-Max DM Max Liquid as shown on Resident #4?s MAR.
Plan of Correction:	Prescriber order was placed in the resident file. All nurses and RMAs re-educated on the medication management policy and to specifically place the written prescriber order in the resident file to ensure compliance. All other resident files were reviewed and there were no concerns. Administrator or designee will ensure adherence to the medication management policy with annual review and training of all staff and observation a medication pass weekly to ensure continued compliance.
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. 1. The December MAR for Resident #1 indicates the following medications were administered late on the following days: Prosource Neutral on 12/28/22, Ferrous Sulfate 325 mg tab on 12/28/22, Aspirin 81 mg tab on 12/28/22, Ensure Liquid on 12/26/22 and 12/28/22, Vitamin B-12 5000 mcg tab on 12/28/22, Vitamin D3 1000 unit tab on 12/28/22, Methenamine Hipp 1 gm tab on 12/26/22 and 12/28/22, Furosemide 20 mg tab on 12/28/22, Fluticasone-Vilanterol 100-25 on 12/28/22, Finasteride 5 mg tab on 12/28/22, DOK 100 mg Softgel on 12/28/22, and Tamsulosin HCL .4mg capsule on 12/26/22. 2. The December MAR for Resident #2 indicates the following medications were administered late or not documented as administered on the following days: Duloxetine LCI 20 mg capsule on 12/09/22, 12/13/22, 12/14/22, 12/19/22, 12/20/22, 12/21/22, and 12/25/22, Melatonin 3 mg tab on 12/11/22, Diclofenac Sodium 1% gel on 12/11/22, 12/23/22, 12/24/22, 12/25/22, and 12/27/22, and Pantoprazole Sod 40 mg tab on 12/24/22, 12/25/22, 12/28/22, and 12/29/22. 3. The December MAR for Resident #4 indicates the following medications were administered late or not documented as administered on the following days: Risperidone 1mg tab on 12/25/22, 12/26/22, 12/27/22 and 12/28/22, Eliquis 5 mg tab on 12/21/22, 12/24/22, 12/25/22 (two doses on 12/25/22) and 12/26/22, Carvedilol 12.5 mg tab on 12/21/22, 12/24/22, 12/25/22 (two doses on 12/25/22) and 12/26/22, Ramipril 5 mg capsule on 12/25/22, Memantine HCL 10 mg tab on 12/25/22, Donepezil HCL 10 mg tab on 12/25/22, and Trazodone 50 mg tab on 12/21/22.
Plan of Correction:	Prescriber and Responsible Parties were notified. There were no adverse effects. All nurses and RMAs re-educated on the medication management policy and to specifically administer and document administration of medications within the identified time frame. Administrator or designee will ensure adherence to the medication management policy with annual review and training of all staff and observation a medication pass weekly to ensure continued compliance.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and observation, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. On the admitting orders for Resident #1, there is an order for Flomax .4 mg tablet to be administered at night; however, the MAR and medication in the medication in the medication cart is in capsule form. 2. The December MAR for Resident #2 indicates the resident received a multivitamin tab on the following days: 12/02/22-12/06/22, 12/08/22-12/10/22, 12/15/22, 12/16/22, 12/19/22-12/21/22, 12/26/22, and 12/27/22. However, during the onsite inspection on 12/29/22, Staff #5 presented a signed discontinued order for the medication dated 11/21/2022.
Plan of Correction:	Prescriber and Responsible Parties were notified. There were no adverse effects. All nurses and RMAs re-educated on the medication management policy and to specifically administer and document administration of medications in accordance with prescriber orders. Administrator or designee will ensure adherence to the medication management policy with annual review and training of all staff and observation a medication pass weekly to ensure continued compliance.
Standard #:	22VAC40-73-925-B
Description:	Based on observation, the facility failed to ensure common face/hand washing sinks have paper towels or an air dryer for hand washing. Evidence: 1. During the onsite inspection on 12/29/2022, the Licensing Inspector did not observe paper towels or an air dryer for hand washing in a hall bathroom used for resident use. The hall bathroom had a hand towel available for use.
Plan of Correction:	Paper towels were replenished. All other areas checked to ensure compliance. Staff were re-inserviced on replenishing supplies and completing supply requests. Administrator or designee will round in the community a minimum of 3 times per week ensure continued compliance.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of hire for each employee. Evidence: 1. The facility did not obtain a completed criminal history record reports for Staff #2 and Staff #6 (both hired 11/17/2022) on or prior to the 30th day of hire.
Plan of Correction:	Staff #2 and 6 were removed from the schedule. All other employee files were checked to ensure compliance. Administrator or designee will review the file of all new hires monthly to ensure compliance.