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: April 30, 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:

22VAC40-73-970

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: 04/30/2024 from 8:30 am to 2:35 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: 64 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: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast and an activity were observed. A medication pass observation was completed for 3 residents. The following were reviewed: resident and staff records, medication carts, call bells, 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 #:	22VAC40-73-580-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:	Virginia Department of Health is waiting on a copy of the Business License for Village at Maimonides of Virginia Beach in order to send out an inspector to complete the required inspection. A copy of the Business License is currently being sent to the Virginia Department of Health so that the inspection can be completed.
Standard #:	22VAC40-73-640-A
Description:	Based on observation and interview, the facility failed to ensure their written plan for medication management includes methods to prevent the use of outdated medications and methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. Evidence: 1. Two bottles of expired Escitalopram Oxalate 20 mg tablets expired 1/20/2024 and 4/6/2024 for Resident #8 were on the medication cart.
Plan of Correction:	Weekly medication cart checks will be completed on Friday of each week and as needed by the Licensed Nurse on duty to ensure that there are no expired medications present on the cart. The Medication Carts are stationed on the First Floor, Memory Enhancement Unit, Second Floor and the Third Floor, each of the carts will be checked.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation, the facility failed to ensure the medication cart be locked and the individual responsible for medication administration keep the keys to the storage area on their person. Evidence: 1. Upon entry into the safe, secure environment around 8:30 am, the medication cart was noted to be unlocked and unattended with medication on top of the cart and the locked section of the cart with narcotics open with the keys in the lock.
Plan of Correction:	All LPN's and Medication Aides were educated on medication cart procedures and safety to include measures to ensure that the cart is secured.
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. Both ISPs for Resident #3 (dated 3/30/24) and Resident #4 (dated 2/27/24) indicate the resident as a DNR; however, Resident #3 and Resident #4 do not have a signed DNR order or Durable DNR in their record.
Plan of Correction:	Both DNR's have been signed by the resident's Primary Care Physician and the Responsible Party. They have been placed in the resident's record.