VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Vero at Chesapeake
757 Cedar Road
Chesapeake, VA 23322
(757) 263-0011

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: June 29, 2023

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:

22VAC40-73-410 22VAC40-73-450 22VAC40-73-1090

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: 6/29/2023 from 9:00 am to 2:10 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: 42 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 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 #:	22VAC40-73-680-C
Description:	Based on observation and 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. Evidence: 1. A medication pass of Resident #5 was observed at 9:49 am with Staff #3. 2. Upon review of Resident #5?s physician orders and MAR, Resident #5 was admitted on 6/6/23 with an order for a Levothyroxine Sodium 125 mcg tablet every morning at 6 am; however, the medication is on the resident?s MAR and administered at 9 am.
Plan of Correction:	1. No residents were negatively affected by this deficient practice. 2. Resident #5?s MAR has been corrected to be equivalent with physician order. 3. All Residents receiving medication services will be reviewed to ensure medication orders coincide with the Medication Administration record. All Licensed staff will be educated on verifying and reconciling all new orders with the current MAR. 4. Health and Wellness Director/Designee will verify before any new order is transcribed to the current E-MAR. The Health and Wellness Director Designee will review the new order and verify with the current MAR on the next business day.
Standard #:	22VAC40-73-720-A
Description:	Based on record review, the facility failed to ensure a valid written Do Not Resuscitate (DNR) order has been issued by the resident's attending physician; and that the written order is included in the individualized service plan. Evidence: 1. Upon review of Resident #4?s record, their ISP (dated 5/30/23), June 2023 MAR, and face sheet indicates the resident as a DNR; however, the resident does not have a signed DNR order or Durable DNR in their record. 2. Upon review of Resident #5?s record, it is inconsistent to Resident #5?s code status as their face sheet indicates the resident is a DNR and their MAR indicates the resident is a full code. Resident #5?s record does not include a signed DNR order or Durable DNR nor does their ISP (dated 6/6/23) does not indicate the resident?s code status.
Plan of Correction:	1. No residents were negatively affected by this deficient practice. 2. Resident #4?s and #5?s record was corrected to be consistent of code status with the physician?s order, Individual Service Plan, Face Sheet, and Medication Administration Record 3. All residents MAR, ISP, Face Sheet, and physician order will be audited for consistency. All licensed staff will be educated on procedures to ensure physicians orders is included in ISP. 4. Health and Wellness Director/Designee will verify that residents code status is properly executed on Move in and as needed, and code status entered into ISP and EMAR.