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: Oct. 5, 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

Technical Assistance:

Written Assurance Form Personal Data

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 10/05/23 from 8:11 am to 6:15 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: 19 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 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Breakfast and lunch were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. The call bell system was monitored. 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 #:	22VAC40-73-40-B
Description:	Based on the onsite record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each staff person. Evidence: 1. The record for staff #3, hire date 3/03/23, contains a criminal record report dated as completed on 05/19/23, which is more than 30 days after staff # 3?s hire date.
Plan of Correction:	Criminal record conducted on staff and updated, with verification from Virginia State Police Moving forward, the facility will ensure that all background checks are conducted in accordance with VDSS instruction 0/7/2023.
Standard #:	22VAC40-73-120-A
Description:	Based on the record review the facility failed to ensure the orientation and training required in subsection B and C of this section shall occur within the first seven working days of employment. Evidence: 1. The record for staff #2, hire date 8/07/23, contains a completion of orientation dated as 9/21/23, which is more than seven days after staff #2?s hire date.
Plan of Correction:	Re-orientation of facility policies, and emergency procedures was conducted for all staff with documentation in staff record The administrator will ensure that all staff are trained, and oriented within seven working days upon hire
Standard #:	22VAC40-73-250-D
Description:	Based on the record review the facility failed to ensure each staff person on or within 7 days prior to the first day of work at the facility shall submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as evidence by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Evidence: 1. The record for staff #1, first day of work on 8/18/23, contains a risk assessment for TB dated 9/28/22, which is more than 30 days prior to staff #1?s first day of work. 2. The record for staff #2, first day of work on 8/07/23, contains a risk assessment for TB dated 9/05/23, which is after staff #2?s first day of work. 3. The record for staff #3, first day of work on 3/03/23, contains a risk assessment for TB dated 5/19/22, which is more than 30 days prior to staff #3?s first day of work.
Plan of Correction:	All staff record have been verified for updated TB screening with verification on file. Administrator will ensure that TB Screening is on file in accordance with VDSS Policy.
Standard #:	22VAC40-73-310-A
Description:	Based on the record review the facility failed to ensure no resident shall be admitted or retained who requires a level of care or service or type of service for which the facility is not licensed. Evidence: 1. The record for resident #2 contains an UAI dated 03/18/23 that documents the resident needs help in bathing, dressing, toileting, eating/feeding, and walking. The UAI documents the resident?s level of care as assisted living. The UAI documents the resident has ?limited vision in both eyes and requires supervision.? During an interview with staff #4, staff #4 confirmed that resident #2 needs physical assistance with bathing, dressing, toileting, eating/feeding, and walking as the resident has limited vision in both eyes. Resident?s #2 physical examination dated 03/09/23 documents a diagnosis of retinopathy. The facility?s current license effective 05/12/23-11/11/23 is licensed for the level of care of residential living only. The facility is not licensed for assisted living level of care and based upon resident?s #2 UAI, the resident needs help in 5 areas for ADL Care and the UAI documents the level of care needed as assisted living.
Plan of Correction:	Based on the UAI, the resident is able to perform IADL.ADL with supervision. Supervision is required for safety. Patient currently have an appointment with the health department to update UAI.
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; the signature of the examining physician or his designee. Evidence: 1. The record for resident #3, admission date 08/01/23, contains a physical examination completed on 8/08/23. The physical exam was completed after the resident?s admission date. 2. The record for resident #4, admission date 5/15/23, contains a physician examination completed on 05/25/23, and a TB risk assessment completed on 04/11/23. The physical exam was completed after the resident?s admission and the resident?s TB risk assessment was completed more than 30 days prior to the resident?s admission into the facility. 3. The record for resident #5, admission date 08/18/23, contains a physical examination completed on 8/28/23. The physical exam was completed after the resident?s admission date. 4. The record for resident #6 contains a physical exam dated 8/7/23, the physical exam did not include the signature of the examining physician or his designee.
Plan of Correction:	Residents was screened prior to admission paperwork incorrectly filed. Both physical paperwork are on file in resident binder. Administrator will ensure that all paperwork are correctly filed and accessible upon request
Standard #:	22VAC40-73-440-A
Description:	Based on the record review the facility failed to ensure all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument (UAI) in accordance with Assessment in Assisted living facilities (22VAC30-110). The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident?s condition. Evidence: 1. Resident?s #1 UAI dated 06/12/23 does not contain documentation of an assessment of the resident?s ADL and IADL needs. 2. Staff #4 confirmed resident?s #1 UAI dated 06/12/23 did not include documentation of the resident?s assessment for ADL and IADL needs. 3. The record for resident #4 contains an UAI dated 09/12/22. The record does not contain an UAI completed annually after 09/12/22. 4. Staff #4 confirmed the record for resident #4 did not contain an UAI completed annually after 09/12/22.
Plan of Correction:	The UAI was completed at residents? prior facility 6/12/23, and the ADL/IADL was confirmed by facility administrator and placed in residents? binder. Resident binder has been updated with complete UAI. Resident #4 has a pending appointment for reassessment/UAI update by the health department. Current status assessed by facility physician does not indicate any changes in resident status as initially stated in previous UAI.
Standard #:	22VAC40-73-450-C
Description:	Based on the record review the facility failed to ensure a comprehensive ISP shall be completed within 30 days after admission and shall include the following: a description of needs and date identified based upon the UAI, admission physical examination, assessment of psychosocial, behavioral, and emotional functioning, and other sources. Evidence: 1. Resident?s #1 physical examination dated 7/18/23 documents a need for treatment for a diagnosis of depression and schizophrenia. The resident?s ISP dated 07/28/23 did not include the resident?s needs for treatment for depression and schizophrenia. 2. Resident?s #2 physical examination dated 3/09/23 documents a need for treatment for a diagnosis of dementia. The resident?s UAI dated 03/13/23 documents a need of supports for bathing, dressing, toileting, and transferring. The resident?s ISP dated 07/14/23 did not include documentation of the resident?s needs for treatment of dementia, and needs for bathing, dressing, toileting, and transferring. 3. Resident?s #4 UAI dated 09/12/22 documents a mechanical and human help need for bathing, and a mechanical support need for walking, stairclimbing, and mobility. The resident?s ISP dated 7/06/23 does not include the needs for bathing, walking, stairclimbing, and mobility. 4. Resident?s #4 physical examination dated 5/25/23 documents dietary needs as low salt, low sugar, and low starch. The resident?s ISP dated 7/06/23 does not include the dietary needs of low salt, low sugar, and low starch. 5. Resident?s #3 psychosocial assessment dated 07/26/23 documents the resident?s behaviors as abusive/aggressive/disruptive, ?verbal threats toward staff.? The resident?s ISP dated 8/01/23 does not include the resident?s behaviors as documented on the psychosocial assessment. 6. The record for resident #4, admission date 5/15/23, contains an ISP dated 7/06/23, which is more than 30 days after the resident?s admission. The record for resident #4 does not contain an ISP or preliminary plan of care completed at admission.
Plan of Correction:	Description of needs indicated on UAI with the exception of mental health (if any) Current residents have updated ISP documenting Moving forward, all ISP will indicate mental health needs if any in accordance with VDSS Policy, and UAI assessments. Residents ISP dated 3/13/23 needs and level of care was during resident hospitalization. Currently, resident is able to perform ADL/IADL and a request for a new UAI update requested from the health department. Cognitive diagnosis of dementia on patient UAI dated 7/14/23 has been updated on the ISP. Dietary needs documented on patient ISP for low sugar and low salt has been incorporated on patient?s ISP. Patient behavior 7/26/23 on the UAI was an incident dated over three years ago and not related to current facility. Current psychosocial and behavioral history reflects past history, and treatment plan with patient monitoring by facility physician, and Chesapeake Integrated Behavioral Health Current plan reflected on patient?s ISP ALL Patient?s ISP has been updated to reflect all psychosocial, ADL, IADL, and mental health