Current Inspector:
Margaret T Pittman
(757) 641-0984
Inspection Date:
Sept. 24, 2024
and
Sept. 25, 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
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: 09/24/2024 from 8:30 am to 3:15 pm and 09/25/2024 from 10:50 am to 1:30 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: 128 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed on 4 residents. The following were reviewed: resident and staff records, emergency preparedness drills, medication carts, and the staff schedule. Water temperature was measured, and the call bell system was monitored.
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.
Based on record review, the facility failed to ensure the comprehensive individualized service plan should include a description of identified needs and date identified based upon the UAI, admission physical examination, and other sources.
Evidence:
1. Resident #1 utilizes an electric scooter and has a NAS diet; however, their use of the electric scooter and their special diet were not documented in their ISP (dated 03/13/2024).
2. Resident #3 utilizes an assistive device (mounted device from floor to ceiling); however, the assistive device was not documented in their ISP (dated 07/02/2024). Additionally, Resident #3 has a DNR (dated 07/24/2024); however, their ISP indicates the resident as a Full Code.
3. Resident #5 admitted to hospice services on 07/30/2024; however, it is not documented on their ISP (dated 11/01/2023).
Plan of Correction:
Unable to retroactively correct ISP to accurately reflect assistive devices and services for residents #1, #3, and #5 prior to the date of inspection.
Health and Wellness Director (HWD) has corrected the ISP for residents #1, #3, and #5 to accurately reflect assistive devices and services. The date of this correction is September 30, 2024.
Executive Director (ED), HWD or designee will retrain licensed nursing associates on the process of accurately documenting changes to the resident?s care plan on the ISP. This training will be completed by October 15, 2024.
To assist with ongoing compliance, the HWD or designee will audit ten percent (10%) of residents? ISP?s weekly for four (4) weeks.
Standard #:
22VAC40-73-930-D
Description:
Based on record review, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility.
Evidence:
1. There was no documentation of 2-hour rounding for Resident #4, Resident #9, Resident #10, and Resident #11 residing within the Crossings, a safe, secure unit.
Plan of Correction:
Unable to retroactively correct documentation of two hour rounds completed for Residents #4, #5, and #10 in the Crossings, a safe, secure, unit.
Health and Wellness Director (HWD) has implemented an electronic nighttime two hour rounding process in electronic record.
Executive Director (ED), HWD or designee will retrain licensed nursing associates on the process of accurately documenting two hour rounds in electronic record. This training will be completed by October 15, 2024.
To assist with ongoing compliance, the HWD or designee will audit ten percent (10%) of residents? two hour rounding log for four (4) weeks.
Standard #:
22VAC40-73-990-C
Description:
Based on interview and record review, the facility failed to document all staff currently on duty on each shift participate in an exercise in which the procedures for resident emergencies are practiced at least once every six months.
Evidence:
1. The facility was unable to provide documentation that all staff currently on duty on each shift participated in an exercise in which the procedures for resident emergencies are practiced at least once every six months.
Plan of Correction:
Unable to retroactively correct documentation of resident emergency drills to reflect that all staff on each shift participated in the drill.
Maintenance Director will follow process of conducting the resident emergency drills in conjunction with the fire drills, which will ensure that all staff on each shift participate in the drill every six months.
Executive Director (ED), or designee will retrain associates on the process of accurately documenting resident emergency drills. This training will be completed by October 15, 2024.
To assist with ongoing compliance, the ED or designee will audit completed resident emergency drills for the next two months.
Standard #:
22VAC40-90-40-B
Description:
Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee.
Evidence:
1. Staff #5 (hired 09/26/2023) did not have a completed history record report in their staff record.
Plan of Correction:
Unable to retroactively correct having a copy of the Virginia State Police criminal history report that was completed for Staff #5 in the staff record.
HR Manager has completed a new Virginia State Police criminal history report for Staff #5 and placed the results of the report in the staff record. The date of this correction is September 24, 2024.
Executive Director (ED), or designee will retrain HR Manager on the process of accurately filing completed criminal history reports. This training will be completed by October 15, 2024.
To assist with ongoing compliance, the ED or designee will audit fifty percent (50%) of newly hired staff records weekly for four (4) weeks.
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
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http://www.dss.virginia.gov/facility/search/alf.cgi