VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Premier Residential and Assisted Living
904 George Washington Hwy North
Chesapeake, VA 23323
(757) 410-2754

Current Inspector: Donesia Peoples (757) 353-0430

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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

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: An unannounced monitoring inspection took place on 06/29/2023 from 8:55 am to 2:55 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: 9 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: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for one resident. Emergency food and water supplies were reviewed. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on the record review the facility failed to ensure within 30 days preceding admission a person shall have a physical examination to include the following: results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form. Evidence: 1. The record for resident #4, admission date 06/06/2023, contains a physical examination and TB test result dated 06/22/2023, which was completed after the resident?s admission date.
Plan of Correction:	All resident records were reviewed and verified for current physical, TB, and admission verification of all required documentation prior to moving in, and admission date. The resident in question does have an updated TB, and all medical information and documentation are verified.
Standard #:	22VAC40-73-350-B
Description:	Based on the record review the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater three days or in fact stays longer than three days and shall document in the resident?s record that this was ascertained and the date the information was ascertained. Evidence: 1. The record for resident # 4, admission date 06/06/2023, does not contain documentation of a completed sex offender screening.
Plan of Correction:	All residents screening against the Virginia State Police Sex Offender registry prior to admission. All present and future residents will have a sex offender screening.
Standard #:	22VAC40-73-410-A
Description:	Based on the record review the facility failed to ensure upon admission, the assisted living facility shall provide an orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of the call system. Acknowledgement of receiving the orientation shall be signed and dated by the resident and, as appropriate his legal guardian, and such documentation shall be kept in the resident?s record. Evidence: 1. The record for resident #3 did not include documentation of an orientation upon his/her admission date of 5/08/2023. 2. The record for resident #4 did not include documentation of an orientation upon his/her admission date of 06/06/2023.
Plan of Correction:	Residents orientations were conducted prior to admission, family members were made aware of the organizational mission, structure, and operations, including call systems, emergency protocols, and respective emergency contact including licensing, ombudsman, and local adult protective services. Corrective action was made with reorientation of residents including; call system emergency procedures, emergency phone locations, emergency exits, and emergency gathering sites in the events of adverse weather, fire, bomb threat, or active shooter in the building. Moving forward, orientation will be conducted by administrative staff within 72 hours of patient?s admission.
Standard #:	22VAC40-73-450-C
Description:	Based on the record review the facility failed to ensure a comprehensive Individualized Service Plan (ISP) shall be completed within 30 days after admission. Evidence: 1. The record for resident #1, admission date of 03/14/23, does not contain a comprehensive ISP.
Plan of Correction:	Corrections made to the Individualized Service Pla (ISPs) to include comprehensive detail including definitive dates, and outcomes for all residents based on the UAI, and changes to resident?s ADL/IADLs.
Standard #:	22VAC40-73-960-B
Description:	Based on observation the facility failed to ensure a fire and emergency evacuation drawing shall show primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers. Evidence: 1. During a tour of the facility with staff #1 the fire and emergency evacuation drawing posted in the facility did not show primary and secondary escape routes, areas of refuge, assembly areas, telephones.
Plan of Correction:	Corrective action complete with emergency evacuation sign posted at all exits, highlighting telephones, fire, refuge, and assembly areas color-coded, and bold print for easy access, and legibility