VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Emily Green Shores
500 Westmoreland Avenue
Portsmouth, VA 23707
(757) 399-3442

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: May 29, 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

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 05/29/24 from 8:22 am to 4:05 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 04/25/24 regarding allegations in the areas of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 31 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Medication carts and availability of medications. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations area of non-compliance with standard(s) or law were: Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-680-D
Description:	Based on the record review the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. The record for resident #1 contains a physician order dated 03/22/24 and 04/03/24 that includes ?Raloxifene 60 mg 1 tab daily every AM, and Vitamin D3 5000 IU plus Vitamin K2 100 mcg, take 1 capsule by mouth daily.? Resident?s #1 incident report documents that the resident was not administered Raloxifene and Vitamin D3 plus Vitamin K2 the dates of 03/22/24 through 04/24/2024. Resident?s #1 MAR record documents the medications (Raloxifene, and Vitamin D3 plus K2) was administered starting 04/25/24.
Plan of Correction:	Medication Aide will ensure that anytime a resident returns from a physician's appointment they will obtain the visit's paperwork and any written orders the physician prescribed for the resident. They will fax orders to the pharmacy then transcribe them onto M.A.R. RCC/Compliance Nurse will review physician's orders and M.A.R.'s weekly for documentation.