VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Village at Maimonides of Virginia Beach
1049 College Park Boulevard
Virginia beach, VA 23464
(757) 282-2384

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

Inspection Date: Feb. 7, 2024

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:

Part V. Admission, Retention and Discharge of Residents

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: 02/07/2024 from 8:35 am to 3:08 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: 65 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 3 residents. The following were reviewed: resident and staff records, medication carts, and water temperatures. 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 #:	22VAC40-73-560-I
Description:	Based on record review, the facility failed to ensure a current picture of each resident be readily available for identification purposes or, if the resident refuses to consent to a picture, there be a narrative physical description, which is annually updated, maintained in his file. Evidence: 1. Resident #1?s record did not include a current picture or a narrative physical description in their resident record.
Plan of Correction:	The recreation/activity department will be responsible for taking a picture and uploading it into each new admission's electronic medical record on the day of admission. The Director of Nursing will notify the Director of recreation/activities on the day a resident is admitted to the facility. In the absence of the Director a member of the recreation/activities staff will be notified of the new admission and the need for the picture to be taken and uploaded into the electronic medical record.
Standard #:	22VAC40-73-580-A
Description:	Based on record review, the facility failed to ensure when any portion of an assisted living facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as evidenced by an initial and subsequent annual reports from the Virginia Department of Health. Evidence: 1. The last health inspection was completed on 01/17/2023.
Plan of Correction:	The Director of the Dietary Department reached out to the Virginia Department of Health on 2/12/24 to follow up on the non-compliance of the required health inspection . She was not able to speak to a representative and has not received a return call. The Dietary Director will be visiting the local office of the Virginia Department of Health in person on 2/14/24 to obtain the date that the overdue inspection will take place. Moving forward, the Dietary Director will reach out to the Virginia Department of Health prior to the due date of the required health inspection to ensure the inspection will be within the required timeframe.
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. Evidence: 1. During a medication observation with Staff #1, Resident #2 was administered the following scheduled 8 am medications at approximately 9:30 am: Aspirin low 81 mg tablet, Midodrine 5 mg tab, Propranolol 10 mg tablet, Ferrous Sulfate 325 mg tablet, Fludrocort .1mg tablet, Levothyroxin 100 mcg tablet, Metronidazol 250 mg tablet, Omeprazole 40 mg capsule, Theratrum tablet, and Vitamin D 25mcg tablet. 2. The January 2024 MAR for Resident #2 indicates the resident received an order to start Erythromycin Ophthalmic 5mg ointment to right eye three times a day for 7 days from 01/04/2024-01/10/2024; however, the ointment was not documented as administered on at least 3 occasions (once on 01/04/2024, 01/05/2024, and 01/08/2024). 3. The January 2024 MAR and February 2024 MAR indicate Resident #4?s Ezetimibe 10 mg tablet was not administered or available on the following days: 01/27/2024, 01/28/2024, 01/30/2024,02/03/2024, and 02/04/2024.
Plan of Correction:	The Director of Nursing provided training to all LPN's and Medication Aides on 2/9/24 and 2/12/24 on the standard dosing schedule of administering medications no earlier than one hour before and no later than one hour after the scheduled time that the medication is due, except the medications that are ordered for specific times. The medication administration record (MAR) will be monitored by the DON or designee for compliance with the standard dosing schedule. The DON or designee will monitor the medication pass monthly on all shifts to ensure that the standard dosing schedule of administering medications no earlier than one hour before and no later than one hour after is being followed per the standard .
Standard #:	22VAC40-73-680-H
Description:	Based on observation and interview, the facility failed to ensure at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the- counter medications and dietary supplements. Evidence: 1. During a medication observation, Staff #1 indicated Resident #2 was administered Creon 360000-unit capsule and Diphen/atrop 2.5 mg tablet at 8 am; however, Staff #1 documented administering the two medications at approximately 9:30 am. 2. Staff #1 acknowledged the two medications were not documented at the time of administration.
Plan of Correction:	The Director of Nursing or designee will monitor the mediation administration record (MAR) daily to ensure that medications are being documented per the physician's order on each shift.