Colonial Manor — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

288

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Colonial Manor was inspected 48 times between January 31, 2021 and September 11, 2025 by the Virginia Department of Social Services. 46 of those visits ended with violations cited and 2 with none. Across that history VDSS cited 288 violations under 98 distinct standards. 14 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window and no longer serves any of these on its site. All 48 are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type

Assisted Living Facility

License type

Provisional

License expires

08/28/2022

Administrator

Dr. Pedro Becerra

Licensing inspector

Darunda Flint

Inspector phone

(757) 807-9731

Approved for

Residential and Assisted Living Care · Non-Ambulatory

Inspection History

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

September 11, 2025Inspection11 violations

Inspection dates

Sept. 11, 2025

Areas reviewed

Comments

Type of inspection: Monitoring An unannounced on-site monitoring inspection was conducted on 9-11-25. (Ar 09: 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: 24 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: Number of interviews conducted with staff: 3 Observations by licensing inspector: medication pass, water temperature, lunch meal Additional Comments/Discussion: 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 (Willie Barnes), Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-210-B

Based on record reviewed and staff interviewed, the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually.

Evidence

On 9-11-25, staff #4’s record noted 10 hours of annual training. Staff’s date of hire (doh) was noted as 6-1-22.
Staff #6’s record noted 9.5 hours of annual training. Staff’s date of date of hire was noted as 5-9-24.
Staff #1 acknowledged the aforementioned staff members did not have the required 18 hours of annual training.

Plan of correction

Not published by VDSS.

22VAC40-73-210-F

Based on record reviewed and staff interviewed, the facility failed to ensure at least two of the required hours of training shall focus on infection control and prevention. When adults with mental impairments reside in the facility, at least four of the required hours shall focus on topics related to the residents? mental impairments.

Evidence

On 9-11-25, staff #4 and #6’s record did not have documentation of annual infection control and prevention training.
Staff #6’s record noted two (2) hours of annual mental health training.
Staff #1 acknowledged the aforementioned staff members record did not include the required hours of infection control and prevention and mental health impairment training hours.

Plan of correction

Not published by VDSS.

22VAC40-73-250-D

Based on record reviewed and staff interviewed, the facility failed to ensure each staff person required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
On 9-11-25, staff #4’s record noted the TB was dated 3-18-24, date of hire 6-1-22.
On 9-11-25, staff #5’s record noted the TB was dated 8-12-24, date of hire 8-12-24.
Staff #1 acknowledged the aforementioned staff members TB was not current.

Plan of correction

Not published by VDSS.

22VAC40-73-260-A

Based on record reviewed and staff interviewed, the facility failed to ensure each direct care staff member shall maintain current certification in first aid The certification must either be in adult first aid or include adult first aid.

Evidence

On 9-11-25, staff member #4’s record did not include a certification in adult first aid.
Staff #1 acknowledged the aforementioned record did not include certification in adult first aid.

Plan of correction

Not published by VDSS.

22VAC40-73-260-B

Based on record reviewed and staff interviewed, the facility failed to ensure staff’s certification in Cardiopulmonary resuscitation (CPR) was current.

Evidence

On 9-11-25, staff member #4’s record included a certification that was noted expired 8-2025.
Staff #1 acknowledged the aforementioned staff member’s CPR certification was not current.

Plan of correction

Not published by VDSS.

22VAC40-73-260-C

Based on document reviewed and staff interviewed, the facility failed to ensure the listing of all staff who have first aid and CPR was kept up to date.

Evidence

On 9-11-25, the first aid and CPR posting located in the nurse’s station/medication room included names of staff members no longer employed and current staff members who FA/CPR had expired: (a) Staff #4, certification expiration date noted as 8/2025; (b) staff member #7’s certification expiration date noted as 2/2025 and (c) staff member #8’s date noted as 8/2025; (b) staff member #7’s certification expiration date noted as 2/2025 and (c) staff member #8’s certification expiration date noted as 7/2025.
Staff #5 not on list, first aid/CPR expires 8/2026.
Staff #1 acknowledged the first and/CPR posting was not kept up to date.

Plan of correction

Not published by VDSS.

22VAC40-73-450-E

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) review and updates of the plan was signed and dated by the licensee, administrator, or designee, and by the resident or the legal representative.

Evidence

On 9-11-25, resident #1’s ISP dated 3-6-25 noted an update to include resident’s physical therapy services (need date 5-12-25) and outcome dated/discontinued (6-30-25). The review/update was not signed and dated by facility staff, the resident and/or the legal representative.
Staff #1 acknowledged the aforementioned resident’s ISP was not signed and dated following an update/review.

Plan of correction

Not published by VDSS.

22VAC40-73-450-F

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs.

Evidence

On 9-11-25, resident #1’s uniform assessment instrument (UAI) dated 3-5-25 noted dressing need assessed as mechanical help/physical assistance. The ISP dated 3-6-25 noted, ?dressing: human help with physical assistance. ..Care aide will assist resident with dressing. Care aide button or zipper up resident clothing when needed?.
Staff #1 acknowledged the aforementioned resident’s UAI assessed need and ISP care services did not agree.

Plan of correction

Not published by VDSS.

22VAC40-73-550-G

Based on record reviewed and staff interviewed, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each staff person and written acknowledgement of having been so informed and shall be filed in the staff person’s record.

Evidence

.
On 9-11-25, staff #5’s record noted resident’s rights and responsibilities was dated 8-12-24. Staff’s date of hire noted as 8-12-24.
Staff #1 acknowledged the aforementioned staff member’s record did not have current rights and responsibilities review.

Plan of correction

Not published by VDSS.

22VAC40-73-860-G

Based on observation and staff interviewed, the facility failed to ensure hot water at taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F.

Evidence

On 9-11-25 during a sample check of water temperatures in residents? room with staff #2, the temperature in room #52 at 9:35 a.m. was 98.6.
Staff #2 acknowledged the water temperature was not within the required range.

Plan of correction

Not published by VDSS.

22VAC40-73-870-D

Based on observation and staff interviewed, the facility failed to ensure the building was kept free of infestation of insects and vermin. The grounds shall be kept free of their breeding places.

Evidence

On 9-11-25, during a tour of the facility with staff #2, bugs were observed in room #29. The bugs were observed in the ceiling in the hallway of the room. Bugs were also noted in the cabinets in the kitchen in the room. Smashed bugs were observed in the door entrance to the room.
Upon entrance to the dining room, a bug was also observed on the napkin on the dining table.
Staff #2 acknowledged the areas of the facility was observed to have bugs/insects.

Plan of correction

Not published by VDSS.

August 25, 2025Inspection8 violations

Inspection dates

Aug. 25, 2025

Areas reviewed

Comments

Type of inspection: Monitoring An unannounced mandated monitoring inspection conducted by two inspectors from the Peninsula Licensing Office (PLO). (Ar. 08:36 a.m./ Dep 14:30 p.m). 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: 25 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 5 Number of staff records reviewed: 2 Number of interviews conducted with residents: Number of interviews conducted with staff: Observations by licensing inspector: breakfast meal, medication pass observation, emergency preparedness Additional Comments/Discussion: 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 (Willie Barnes), Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-160-E

Based on record reviewed, the facility failed to ensure the administrator who supervises medication aides shall be required to annually have four hours of training in medication administration specific to the facility population or a refresher course in medication administration offered by a Virginia Board of Nursing approved program.

Evidence

On 8-25-25, staff #1’s record did not have documentation of the annual medication refresher course. The date of the last training date was 6-13-24.

Plan of correction

Not published by VDSS.

22VAC40-73-210-B

Based on record reviewed, the facility failed to ensure facility licensed for both residential and assisted living care, direct care staff who are licensed health care professionals shall attend at least 12 hours of annual training.

Evidence

On 8-25-25, staff #2’s record did not include documentation of 12 hours of annual training. Staff’s date of hire noted
Staff #2 acknowledged record did not have documentation of annual training.

Plan of correction

Not published by VDSS.

22VAC40-73-210-F

Based on record reviewed, and staff interviewed, the facility failed to ensure at least two of the required hours of staff training shall focus on infection control and prevention.

Evidence

On 8-25-25, staff #1 and #2’s record did not include documentation of infection control training.
Staff #2 acknowledged, the aforementioned staffs? record did not include required training.

Plan of correction

Not published by VDSS.

22VAC40-73-440-H

Based on record reviewed, the facility failed to ensure an annual reassessment, using the uniform assessment instrument (UAI) was utilized to determine whether a resident’s needs can continue to be met by the facility and whether continued placement in the facility is in the best interests of the residents.

Evidence

On 8-25-25, resident #1’s record did not include an annual assessment. The resident’s record noted the resident is classified as an Auxiliary Grant receipt. The date of the last public pay UAI in the record was dated 10-31-23.
Staff #2 acknowledged the aforementioned resident’s record did not include a current public pay UAI.

Plan of correction

Not published by VDSS.

22VAC40-73-450-F

Based on record reviewed, the resident’s individualized service plan (ISP) did not include all assessed information.

Evidence

On 8-25-25, resident #1’s ISP dated 11-1-24 noted stairclimbing assessed as mechanical help (mh) needed. The ISP did not include what type of mechanical tool was needed to assist the resident with stairclimbing.
Staff #2 acknowledged the aforementioned resident’s record did not include all assessed needs.

Plan of correction

Not published by VDSS.

22VAC40-73-610-B

Based on document reviewed and staff interviewed, the facility failed to ensure any menu substitutions or additions shall be recorded on the posted menu.

Evidence

On 8-25-25, the posted menu noted, “seasoned potato cubes, ham, fried eggs, fruit, ” cup grits or “ cup dry cereal”. The inspector did not observe ham on the plates. Staff #4 stated ham was substituted for bacon or some other meat. This was not documented on the menu posted in the hallway for the residents and not on the menu in the kitchen.
Staff #4 acknowledged the menu was not updated to include the substituted item.

Plan of correction

Not published by VDSS.

22VAC40-73-950-A

Based on interview, the facility failed to ensure it had documentation of annual contact with the local emergency coordinator’s review of the written emergency preparedness and response plan.

Evidence

On 8-25-25, staff #2 and #3 did not have documentation of the facility’s annual review of the facility’s emergency preparedness and response plan from the local emergency coordinator.

Plan of correction

Not published by VDSS.

22VAC40-73-990-C

Based on document reviewed and staff interviewed, the facility failed to ensure at least every six months, all staff currently on duty on each shift participate in an exercise in which the procedures for resident emergencies are practiced.

Evidence

On 8-25-25, the facility did not have documentation of staffs? participation in an exercise in which the procedures for resident emergencies are practiced.
Staff #2 and #3 acknowledged not having documentation of resident emergency practice.

Plan of correction

Not published by VDSS.

July 25, 2025Inspection2 violations

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments

Type of inspection: Monitoring An unannounced monitoring inspection conducted on 7/25/2025 by two inspectors, (Ar. 09:36 a.m./ Dep. 12:30 p.m.) 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: 25 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: Number of interviews conducted with staff: 2 Observations by licensing inspector: lunch meal observation, first aid kits (vehicle and nursing station; emergency preparedness Additional Comments/Discussion: 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-450-F

Based on record reviewed and staff interviewed, the facility failed to ensure the reviewed and updated individualized service plan (ISP) included all the required information.

Evidence

On 7-25-25, resident #1’s uniformed assessment instrument (UAI) dated 10-3-24 noted resident’s behavior assessed as abusive/aggressive/disruptive- less than weekly. The ISP dated 10-3-24, page 7 documented, ?Behavioral Pattern: Appropriate (Emotional)“. Orientation need assessed on UAI as ”disoriented, some spheres, all the time?. Spheres affected not documented. The ISP, page 8, documented, “Orientation: Oriented”.
Resident #2’s physician’s orders dated 6-26-25 noted resident’s allergy to cheese. The ISP dated 4-3-25 did not include resident’s cheese allergy.
During the preliminary exit on 7-25-25, staff #1 and #3 acknowledged the aforementioned residents? assessed needs and the ISP did not agree.

Plan of correction

Not published by VDSS.

22VAC40-73-990-C

Based on document reviewed and staff interviewed, the facility failed to ensure at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years.

Evidence

On 7-25-25, a request for the resident emergency practice document was made. The document in the facility was dated Sept 2023. The facility was requested to forward the current document dated March 2025 on the ?What your Inspector Needs document? to the licensing office by close of business 7-28-25. Staff #1 stated, documents would be sent.
On 7-28-25, a copy of the emergency preparedness and resident emergency plan 2025 was received. However, it did not include the names/signature of staff members. Staff #2 acknowledged the document was not signed/dated by staff members, only the administrator and assistant to administrator.

Plan of correction

Not published by VDSS.

June 12, 2025Inspection0 violations

Areas reviewed

Comments

Type of inspection: Monitoring An unannounced monitoring inspection conducted on 6-12-25 by two inspectors, (Ar. 10:20 a.m./ Dep. 15:00 p.m.) 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: 25 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: medication pass observation, lunch meal, first aid kits (vehicle and nursing station) Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 12, 2025Complaint survey0 violations

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint An unannounced complaint inspection was conducted on 6-12-24 by two inspectors from the Peninsula Licensing Office (PLO). Ar 08:30 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 6-6-25 regarding allegations in the areas of resident care; funding and building and grounds. Number of residents present at the facility at the beginning of the inspection: 25 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: Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 5 Observations by licensing inspector: medications- building Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Willie Barnes, Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

May 19, 2025Inspection2 violations

Inspection dates

May 19, 2025 and May 20, 2025

Areas reviewed

Comments

Type of inspection: Monitoring An unannounced monitoring inspection conducted on 5-19-25 by two inspectors, (Ar. 08:35 a.m./ Dep. 1:05 p.m.) On 5-20-25, one inspector (Ar. 4:20 p.m./ Dep 4: 37 p.m.) 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: 25 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: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: medication pass observation, lunch meal, first aid kits (vehicle and nursing station) Additional Comments/Discussion: 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-460-A

Based on record reviewed, resident interviewed, staff interviewed and observation, the facility failed to ensure medication was administered in accordance with the physician’s or other prescriber’s instructions.

Evidence

On 5-19-25 during lunch hour, resident #1 showed the inspectors a dark green and white capsule in a souffle cup at the lunch table. Resident asked the inspectors if resident should take medication. The inspectors asked the resident where the resident got the medication, to which resident responded, “from the nurse”. The facility does not have nurses on staff, only registered medication aides (RMA). The resident stated not taking medication and had other pills in the resident’s room. The inspectors and resident went to the resident’s room and the resident went to the cabinet in the common area of the room and removed a sandwich sized clear plastic zip locked bag that contained many pills that resembled the dark green and while capsule in the souffle cup. The RMA arrived and was shown the medications presented to the inspectors by resident #1. A count of the medication was requested by the inspectors. The medication counted by the RMA totaled 320 pills, this included the one from lunch hour.
The medications were identified as Hydroxyzine Pamoate (Vistaril). The resident’s physician’s order signed and dated 2-6-25 noted resident prescribed Hydroxyzine Pamoate 50 mg capsule, 1 capsule 2 times a day at 8 am and 2 pm for agitation.
Resident #1’s January 2025 to May 2025 medication administration records (MARs) were reviewed. The documents noted medication given and refusals. There was no documentation of medication errors or disposal of medications.
Staff #1 and #3 acknowledged the number of pills in the resident’s possession and the resident should not have had the pills.

Plan of correction

Not published by VDSS.

22VAC40-73-680-D

Based on observation and record review the facility failed to ensure medication was administered in accordance with the physician’s or other prescriber’s instructions.

Evidence

On 5-19-25, resident #1 was observed to be in possession of a prescribed medication (Vistaril 50 mg capsule) in a white souffle cup at the table during lunch hour. The resident is prescribed this medication twice a day, at 8 a.m. and 2 p.m. The medication administration record (MAR) noted the 2 p.m. medication was administered.
Resident #1’s uniformed assessment instrument (UAI) dated 4-3-25 and Individualized Service Plan (ISP) dated 4-3-25 noted resident’s medication is administered by the facility staff. The resident does not self-administer any medications.
Staff #3 stated the medication was given to the resident but staff #3 did not stay to determine if the resident had taken the medication.

Plan of correction

Not published by VDSS.

April 21, 2025Inspection4 violations

Areas reviewed

Technical assistance

Plan of correction not provided by licensee for this inspection.

Comments

Type of inspection: Monitoring An unannounced non-mandated monitoring inspection was conducted by two Peninsula Licensing Inspectors on 4-21-25. (Ar. 08:40 a.m./ Dep. 12:30 p.m.) 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: 25 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: medication pass observation, tour of facility Additional Comments/Discussion: 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 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-320-B

Based on record reviewed and staff interviewed, the facility failed to ensure the risk assessment for tuberculosis (TB) was completed annually for a resident.

Evidence

On 4-21-25, resident # 3’s TB risk assessment was not dated. The last assessment in the record was dated 3-18-24. The resident’s date of admit was noted as 10-1-10.
Staff #1 and #2 acknowledged the resident’s TB was not dated.

Plan of correction

The issue was corrected while the licensing inspector was still on-site. The nurse who completed the assessment dated the form at that time. Date of Correction: April 21, 2025

22VAC40-73-325-B

Based on documents reviewed and staff interviewed, the facility failed to ensure the fall risk rating was reviewed and updated at least annually for the residents.

Evidence

On 4-21-25, there were fourteen (14) residents fall risk rating that was not reviewed and updated at least annually. Eleven of the fourteen were dated 3-24-24; one dated 3-21-24, one dated 3-25-24, and one dated 4-1-24.
Staff #1 and #2 acknowledged the residents? fall risk rating were not reviewed and updated at least annually.

Plan of correction

The Assistant Administrator provided education to the RMA on charge, emphasizing the requirement to complete fall risk assessments not only after each fall incident but also annually in conjunction with the UAI and Care Plan annual assessments. Date Corrected: April 21, 2025

22VAC40-73-430-H-1

Based on document reviewed and staff interviewed, the facility failed to ensure the discharge statement included all required information.

Evidence

Based on document reviewed and staff interviewed, the facility failed to ensure the discharge statement included all required information. Evidence:
On 4-21-25, resident #3’s discharge document did not include the date the discharge statement was provided to the resident and or public pay representative. The document did not include the method of notification nor the date of notification of the planned discharge and the reason for the discharge. The facility did not document the actions taken by the facility to assist the resident id the discharge and relocation process if applicable.
Staff #2 acknowledged all information was not documented on the discharge statement.

Plan of correction

An email was sent to the public pay representative and will be attached to the discharge form to serve as documentation of the notification. Staff have been reminded of the requirement to complete all sections of the discharge documentation, including the date, method of notification, reason for discharge, and any assistance provided to the resident. Date Corrected: April 21, 2025

22VAC40-73-440-K

Based on record reviewed and staff interviewed, the facility failed to ensure the uniformed assessment instrument (UAI) was accurately completed for a resident.

Evidence

On 4-21-25, resident #1’s noted wheeling need as, “no help and not performed”. The resident was observed and did not need a wheelchair and would be capable of using a wheelchair if needed.
Staff #1 acknowledged the resident’s need for wheeling on the UAI was not correctly assessed.

Plan of correction

It was clarified to the licensing inspector that the original entry was a typographical error on the form. A new, updated assessment was completed to accurately reflect the resident’s current mobility status. Date Corrected: April 21, 2025

March 19, 2025Inspection1 violation

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments

Type of inspection: Monitoring An unannounced monitoring inspection was conducted on 3-19-25 with two inspectors from the Peninsula Licensing Office. (Ar 08:35 a.m./ Dep 12:32 p.m.) 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: 27 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication pass, lunch menu, activity Additional Comments/Discussion: 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-450-F

Based on record reviewed and staff interviewed, the facility failed to ensure the reviewed and updated individualized service plan (ISP) included all the required information.

Evidence

On 3-19-25, resident #1’s uniformed assessment instrument (UAI) 5-8-24 noted bathing need assessed as no help. Resident’s ISP dated 5-8-24 noted bathing, resident requires reminders to take bath, prompts. Walking assessed as no help needed; ISP noted resident requires supervision, “occasionally observed use the handrails around the building”. Resident assessed as oriented; ISP noted, occasionally, may exhibit delusions of being a detective and talk about investigations staff will attempt to redirection should resident argue or become agitated, allow to go to room PRN medication may be used to help calm resident if agitation persist, contact family and allow family to speak with resident.
Staff #1 and #2 acknowledged the resident is disoriented and agitated at times.

Plan of correction

Updated the UAI & ISP to align with one another. All staff members are certified to do the UAI for each Residents now. Date Completed: April 3, 2025

February 27, 2025Inspection1 violation

Inspection dates

Feb. 27, 2025

Areas reviewed

Comments

Type of inspection: Monitoring An unannounced monitoring inspection was conducted by two inspectors from the Peninsula Licensing Office (PLO) on 2-27-25. (Ar. 08:30 a.m./ Dep 13:42 p.m.) 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: 27 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 1 Number of interviews conducted with residents: Number of interviews conducted with staff: 3 Observations by licensing inspector: Medication cart check Additional Comments/Discussion: 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-450-F

Based on record reviewed and staff interviewed, the facility failed to ensure the reviewed and updated individualized service plan (ISP) included all the required information.

Evidence

On 2-27-25, resident #1’s uniformed assessment instrument dated 7-23-24 documented resident incontinent of bowel and bladder greater than weekly. The resident’s ISP dated 7-25-24 documented, ?resident manages bowel regimen independently-resident goes to the bathroom independently for the bowel. Occasional accidents on the bowel. Resident uses briefs and prompting from the staff is needed when to change it.? Resident assessed as disoriented some spheres (time and place) all the time. Resident assessed as having short-term memory loss. The ISP noted the resident is ?always disoriented in some spheres like place and time; resident knows the year but is not sure. Resident is okay remembering the person talking to him?. The ISP did not address what services the resident will be provided when resident does not remember. The assessed short-term memory loss is not documented on the ISP.
Staff #1 and #2 acknowledged the resident’s ISP did not include all required information for assessed needs.

Plan of correction

The resident's Individual Service Plans (ISPs) and Uniform Assessments (UAIs) have been updated, and a private UAI has been created, as the caseworker conducts evaluations on an annual basis. This ensures that care staff will reference the UAI to guide the development and implementation of the residents' care plans. Date Corrected: March 3, 2025

February 21, 2025Inspection7 violations

Inspection dates

Feb. 21, 2025

Areas reviewed

Technical assistance

Technical assistance: 750-B (sheered window covering at the window in room 52 does not provide for privacy, one can see through the curtains and see outside, room is on the side that faces the highway). 640-A- medication management policy does not include all required components. i.e., facility’s dosage time, all requirements for physician’s orders; medication destruction process; etc..

Comments

Type of inspection: Monitoring An on-site non-mandated monitoring inspection was conducted by two Peninsula Licensing Inspectors (PLO) on 1-31-25. (Ar 08:50 a.m./Dep 14:20 p.m.) 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: 27 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: Number of interviews conducted with staff: 3 Observations by licensing inspector: call bell check, water temperature check, medication cart check, first aid kit check Additional Comments/Discussion: 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 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-150-F

Based on document reviewed and staff interviewed, the facility failed to ensure the facility licensed for both residential and assisted living care, the administrator served on a full-time basis as the on-site agent of the licensee and shall be responsible for the day-to-day administration and management of the facility.

Evidence

On 1-31-25, the ?Admin Schedule dated January 12 to February 22, 2025, noted the following hours for staff #1: (a) Week 1-12-25 to 1-18-25 noted 29 hours. (b) Week 1-19-25 to 1-25-25 noted 34 hours. (c) Week 1-26-25 to 2-1-25 noted 14 hours as of 1-31-25, schedule for 1-31-25 not start time of 11a.
Staff #1 was reminded of the standards regarding full-time requirements for the administrator.

Plan of correction

The administrator will submit his hours to the assistant administrator to ensure they are posted in the schedule. Individual is required to complete a minimum of 40 hours per week. Date to be Completed: February 1, 2025

22VAC40-73-660-A-6

Based on observation and staff interviewed, the facility failed to ensure medication for a resident was refrigerated as required.

Evidence

On 1-31-25, during a medication cart check with staff #3, resident #1’s Lorazepam Intensol Oral Concentrate noted an open date of 12-13-23. A white and blue label was observed on the plastic bag which contained the medication. The label noted the word “Refrigerate”. An Inspection of the medication bottle noted the label noted, ?Store at cold temperature. Refrigerate at 2 degrees to 8 degrees Celsius (36-to 46 degrees Fahrenheit).
Staff #3 acknowledged resident #1’s Lorazepam Intensol Oral Concentrate was on the medication cart and not in the refrigerator.

Plan of correction

It was discovered that the expired medication was left in the cart. To prevent this issue in the future, all expired medications will be collected at the end of each month and disposed of properly. This procedure will ensure that expired medications are not administered, and that the medication cart remains properly stocked. Date Corrected: March 1, 2025

22VAC40-73-680-C

Based on document reviewed and staff interviewed, the facility failed to ensure medications shall be administered not earlier than one hour before and not later than one hour after the facility’s dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.

Evidence

On 1-31-25, resident #1’s January 2025 medication administration record (MAR) noted the following medications administered outside of the dosing schedule: (a) 1-1-25, 8:00 a.m. medications given at 9:28 a.m. (b) 11-5-25, 8:00 a.m. medications given at 9:28 a.m. (c) 1-14-25, 8:00 p.m. medication given at 9:18 p.m. The December 2024 MAR noted the following medications administered outside the dosing schedule: (a) 12-18-24, 8:00 a.m. medications given at 9:19 a.m. (b) 12-23-24, 8:00 a.m. medications given at 9:38 a.m. and (c) 12-25-24, 8:00 a.m. medications given at 9:45 a.m.
Resident #2’s January 2025 MAR noted the following medications administered outside the dosing schedule: (a) 1-1- 25 8:00 a.m. medications given at 9:55 a.m. (b) 1-5-25 8:00 a.m. medications given at 9:42 a.m. (c) 1-9-25, 8:00 a.m. medications given at 9:34 a.m. (d) 1-14-25 9:00 p.m. medications given at 10:59 p.m. (e) 1-20-25 8:00 a.m. medications given at 9:20 a.m. and (f) 1-31-25, 6:00 a.m. medications given at 4:04 a.m.
Staff #1 acknowledged the residents? medication were not administered within one hour before and not later than one hour after the time noted on the residents? MARs and physician’s orders.

Plan of correction

All Registered Medication Aides (RMAs) chart immediately after each medication administration, including the medication name, dose, route, time, and patient response. If charting is delayed, RMAs must note the reason in the Medication Administration Record (MAR), confirming the medication was given on time. A Medication Administration and Charting Protocol will be reviewed by all RMAs to prevent late charting without proper notes. RMAs will be held accountable through regular audits, with retraining or disciplinary action for repeated offenses. Feedback will be provided to maintain accurate and timely charting practices. Date to be Completed: February 14, 2025

22VAC40-73-680-D

Based on document reviewed observation and staff interviewed the facility failed to ensure that a resident’s medication Description: Based on document reviewed, observation, and staff interviewed, the facility failed to ensure that a resident’s medication was administered in accordance with the physician’s or other prescriber’s instructions.

Evidence

On 1-31-25, during a check of the medication cart with staff #3, resident #1’s Haloperidol Lactate 2mg/ml concentrate was dated 9-18-24. The January 2025 medication administration record (MAR) noted ?give 1ml/2mg 2 times a day LAR agrees to mix liquid into food or liquid?. The bottle noted a quantity of 120. Staff #3 was shown the date on the bottle and the quantity on the bottle and shown that the bottle was not empty. The LI’s inquired why this medication was being administered and remained on the cart based on the information on the bottle and the January 2025 MAR. The physician’s order also noted, give 2 mg twice a day. Staff #2 stated the resident refuses. A check of the resident’s August 2024 to January 2025 MAR did not document any refusals by the resident. Staff #1 reviewed the Haloperidol bottle label which noted 120 quantity and acknowledged the medication should have been re-order or another bottle available. The current bottle should have been completed prior to 1-31-25.
The facility’s pharmacy representative stated sending the facility a new bottle in December 2024. The 120-quantity administered twice a day would be 60- day supply.
Staff #1 acknowledged the resident’s medication was not administered as prescribed.

Plan of correction

RMAs have been educated on the importance of charting when a resident refuses medication. Additionally, they have been instructed to ensure that liquid medications are properly administered with the correct measurements. These steps will help maintain accurate records and ensure safe medication administration. Date to be Corrected: February 14, 2025

22VAC40-73-680-E

Based on document reviewed, staff interviewed and observation, the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. This documentation shall be maintained in the resident’s record.

Evidence

On 1-31-25, resident #2 observed in the dining room during lunch, wearing white above ankle socks. The resident’s January 2025 medication administration record (MAR) noted the resident “Ted Knee Hi BGE XL Reg,” prescribed to be placed “on every morning & off at bedtime for edema ”XL open toe knee high?. The MAR noted the Ted hose was signed by staff on 1-31-25 as completed at 8:00 a.m. The resident’s record contained a physician’s orders dated 1-16-25 noted resident’s Ted Knee Hi -open toe knee high.
Staff #1 acknowledged resident’s Ted hose was not applied per physician’s order and as noted on the resident's January 2025 MAR.

Plan of correction

To avoid confusion, the provider has removed the PRN order for Ted Knee Hi stockings and kept only the scheduled order. RMAs should follow the scheduled order and disregard the PRN order. Any unclear orders should be immediately reported to the provider for clarification. Date to be Corrected: February 14, 2025

22VAC40-73-680-I

Based on documents reviewed and staff interviewed, the facility failed to ensure the medication administration record (MAR) included all requirements.

Evidence

On 1-31-25, resident #1’s January medication administration record (MAR) was missing staff initials on 1-11-25 for Haloperidol (8:00 p.m.) December 2024 MAR was missing staff initials on 12-27-24 for Centrum, Crushable medications and Haloperidol (8:00 a.m.) and Sertraline (9:00 a.m.).
Resident #2’s January 2025 MAR was missing staff initials for ten administrations for Atorvastatin (8:00 p.m.); (b) one administration for Citalopram (5:00 p.m.); (c) two administrations for Furosemide (8:00 p.m.); (d) ten administrations for Hydrocortisone Lotion (8:00 p.m.); (e) three administrations for Levothyroxine (6:00 a.m.); (e) five administrations for Lubrifresh P.M. Eye Ointment; (f) ten administrations for Nystatin topical powder (8:00 p.m.); (g) Oxygen checks eleven times at 7:00 p.m. and one check at 12:00 a.m.; (h) one administration for Primidone at 5:00 p.m.; (i) Ten administration for Polytrim Eye Solution (8:00 p.m.); (j) fourteen administration for Hydrocortisone Cream (9:00 a.m.) and thirty administration for Hydrocortisone Cream (7:00 p.m.).
Staff #1 acknowledged the residents? MARs did not include the initials of the staff administering medication.

Plan of correction

Upon reviewing the charting, it was found that the RMA has not been completing charting immediately after administering medications. To address this issue, a scheduled class from the pharmacy will be provided to reinforce proper charting procedures and ensure compliance with the medication administration protocol. Regular monitoring will be conducted to ensure full adherence moving forward. Date to be corrected: March 1, 2025

22VAC40-73-680-K

Based on record reviewed and staff interviewed, the facility failed to ensure when medication aides administer the PRN (as needed) medication when the facility has obtained from the resident’s physician or other prescriber a detailed medical order, the order included all required information. The order shall include the symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period and directions as to what to do if symptoms persist.

Evidence

On 1-31-25, resident #1’s January 2025 medication administration order (MAR) noted Acetaminophen 325mg tablet, two tablets by mouth every 4 to 6 hours as needed for pain. Ibuprofen 200 mg capsules by mouth every 6 to 8 hours as needed for pain. The medications did not have the exact time frames. Resident prescribed Sodium Chloride 5% eye drop, the MAR noted, ?Instill ---need amount of drops--- as needed for dry eyes. The number of drops and specific eyes was not noted. The physician’s orders dated 1-2-25 did not include exact dosage for eyedrops and exact time for acetaminophen and Ibuprofen.
Staff #2 acknowledged the resident’s MAR did not include the exact times and dosage to be administered.

Plan of correction

A meeting was held with the provider, during which it was emphasized that medication orders must include the exact dosage, time, and symptoms indicating the need for the medication. The provider corrected the orders immediately to ensure they met these requirements. Going forward, all orders will be reviewed to ensure they contain the necessary details to avoid any confusion. Date to be Corrected: February 12, 2025

January 14, 2025Complaint survey4 violations

Inspection dates

Jan. 14, 2025

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint An on-site unannounced inspection was conducted on 1-14-25 by two inspectors from the Peninsula Licensing Office. (Ar 08:24 a.m./Dep 11:30 a.m.). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report incident was received by VDSS Division of Licensing on 12-10-24 regarding allegations in the resident care and related services, elopement of a resident. Number of residents present at the facility at the beginning of the inspection: 27 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: 1 Number of interviews conducted with staff: 6 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were 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. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-440-H

The facility failed to complete a reassessment due to a significant change in the resident's condition, using the UAI, to determine whether a resident's needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.

Evidence

The uniformed assessment instrument (UAI) for resident #1, dated 4-30-24, was not updated to reflect a significant change in the resident condition as indicated on the facility’s RAWS assessment dated 11-8-2024 and the completed nurse practitioner assessment dated 02-13-2023.

Plan of correction

The Uniform Assessment Instrument (UAI) has been reviewed and updated to accurately reflect the resident’s current condition.

22VAC40-73-450-F

Based on record reviewed and staff interviewed, the facility failed to review and update the individualized service plan (ISP) for a significant change in the resident’s condition.

Evidence

On 1-14-25, the facility’s “Revised Algase Wandering Scale (RAWS) Assessment form dated 11-8-24, question #19, ” Previous Elopement circled response as multiple attempts?. The resident’s uniformed assessment instrument (UAI) dated 4-30-24 did not document wandering as a behavior pattern. The resident’s individualized service plan (ISP) dated 4- 30-24 did not include this assessed need.
The resident’s UAI noted orientation need; resident is disoriented some spheres, sometime. The ISP noted the resident, carries a talking clock to remind resident about the time. Staff #3 stated the resident’s clock was not being used because the clock was broken.

Plan of correction

The UAI has been revised and updated to align with the resident’s current condition.

22VAC40-73-460-A

Based on documents reviewed and interviews, the facility failed to ensure it provided for the health, safety, and well-being of a resident.

Evidence

On 1-14-25, two licensing inspectors conducted an inspection regarding an email from staff #1 on 12-10-24, informing the inspector that resident #1, ?got out of the building that morning about 9:40 a.m. and went in to the neighbors House Who called us, to pick up resident #1“ resident #1 was back in to building by 10:10” (sic).
Resident #1, a ninety-four (94-year-old with dementia) on the morning of 12-10-24 crossed a two-laned street/road, using the rollator walker for mobility. The speed on the road between the facility and the neighbor’s house is 45 mph. The neighbor’s house is approximately 0.2 miles from the facility.
The temperature on the morning of 12-10-24 according to ACCU weather was a low of 43 degrees Fahrenheit (F) and a high of 65 degrees F.
On 2-14-25, Interview with CC-2 stated, heard knocking at the front door, and observed through door-camera, an elderly lady with a walker at the front door of CC-2 `s house. CC-2 stated contacted the police, because the resident was agitated and had a pair of scissors. CC-2 stated called the facility across the street and informed them of someone on CC-2’s doorstep. The local police document noted a call from the neighbor’s residence at 09:44 a.m. and arrival at 10:00 a.m. The 12-10-24 police report noted, caller stating resident had scissors and noted resident saying someone is trying to kill resident.
The facility final written incident report requested on 1-14-25 noted, ?approximately 09:15 AM, resident was observed by the Activity Coordinator walking in the hallway after breakfast. After 20-30 minutes, the facility received a phone call from a neighbor stating that a resident, later identified as resident #1 was at the neighbor’s front door knocking?. Three staff members went to the neighbor's house and assisted the resident in returning to the facility safely?.
Staff #2 stated, staff members were not aware the resident was not in the facility until the facility received a call from the neighbor informing them of the resident’s whereabouts.
Staff #7 stated resident # 1 was agitated earlier that morning in the dining room during breakfast. The resident was removed from the dining room and taken to the resident’s bedroom. Staff members #5, #6 and #7 were informed by staff #2, that the resident was across the street at a neighbor’s house. Staff #5, #6, and #7 went to the home and returned the resident to facility.
Staff #2, #5, #6, and #7, acknowledged the resident’s absence without staff knowledge on the morning of 12-10-24.

Plan of correction

Medications have been appropriately adjusted, and the UAI and Individualized Service Plan (ISP) have been updated to reflect the resident’s current condition. Additionally, hourly checks will be implemented whenever the resident exhibits challenging behaviors on a daily basis.

22VAC40-73-460-D

Based on documents reviewed and interviews, the facility failed to ensure it provided supervision of a resident’s schedule, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.

Evidence

On 01-14-25, an inspection was conducted. Resident #1’s record included a ?Revised Algase Wandering Scale (RAWS) Assessment form completed by an unknown assessor dated 11-8-24. Question #2 noted, ?Wandering history, occasionally wanders, with a high-risk score of 3“. Question #19 noted, ”Previous Elopement, multiple attempts, with a high-risk score of 3?. The resident’s uniformed assessment instrument (UAI) dated 4-30-24 did not document wandering as a behavior pattern. The resident’s individualized service plan (ISP) dated 4-30-24 did not include this assessed need. The resident’s UAI noted orientation need; resident is disoriented some spheres, sometime. The ISP noted the resident, carries a talking clock to remind resident about the time. Staff #3 stated the resident’s clock was not being used because the clock was broken.
The Nurse Practitioner’s assessment dated 2-13-23 documented the resident's memory loss, dementia with behavioral disturbances, dementia with mood disturbances, and anxiety. The resident prescribed psychotropic medication for agitation.
Interviews with staff #5, #6 and #7, who returned the resident to the facility stated the resident would get out many times. Staff would observe resident in the parking lot of the facility or outside in back area/smoking area of facility and bring resident back inside the facility.

Plan of correction

Medications have been adjusted, and both the UAI and ISP have been revised to accurately reflect the resident’s current condition. Furthermore, hourly checks will be conducted whenever the resident exhibits challenging behaviors on a daily basis.

December 27, 2024Inspection9 violations

Inspection dates

Dec. 27, 2024

Areas reviewed

Comments

Type of inspection: Monitoring An unannounced monitoring inspection was conducted on 12-27-24 by two inspectors from the PLO. Ar 08:35 a.m./Dep 14:00. 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: 27 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: medication pass observation, breakfast, water temperatures, Additional Comments/Discussion: 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-100-C-2

Based on observations and staff interviewed, the facility failed to ensure implementation of blood glucose monitoring practices that are consistent with CDC recommendations. When assisted blood glucose monitoring is required, fingerstick devices shall not be used for more than one person.

Evidence

On 12-27-24 during medication pass observation, staff #3 utilized resident #5’s glucometer to complete the finger stick for resident #1. Resident #5’s glucometer container was not labeled but the glucometer instrument was labeled with #5’s name. A check of the other glucometers on the two medication carts was conducted with staff #3. Resident #1’s glucometer container and instrument were located and was labeled with resident #1’s information.
Staff #3 acknowledged not checking the glucometer instruments for the correct resident’s instrument prior to completing resident’s finger stick.

Plan of correction

A red flag will be added to the medication carts to signal when glucometer testing or medication passes are taking place, ensuring staff are not interrupted during these tasks. Additionally, all glucometer containers will be clearly labeled with the residents? information to avoid any confusion. Staff will receive training on proper labeling procedures and the importance of checking glucometers before use. These actions will be monitored through regular checks and audits to ensure compliance. Date to be Corrected: February 1, 2025

22VAC40-73-310-H

Based on record reviewed, documents reviewed, and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibition condition per the Code of Virginia 63.2-1805 D.

Evidence

On 12-27-24, resident #1’s physician order dated 7-29-24 noted resident prescribe Benztropine for psychosis. The resident’s December 2024 medication administration record (MAR) also noted the psychotropic medication. The record did not include a treatment plan for this psychotropic medication.

Plan of correction

noted Shawn prescribe Benztropine for psychosis. The resident’s December 2024 medication administration record (MAR) also noted the psychotropic medication. The record did not include a treatment plan for this psychotropic medication.

22VAC40-73-450-F

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed for significant change of a resident’s condition or assessed needs.

Evidence

On 12-27-24, resident #3’s uniformed assessment instrument (UAI) dated 9-9-24 noted walking need assessed as mechanical help (mh). The ISP dated 11-8-24 noted walking need: mechanical help. Resident ?walks independently without any help or supervision“. Mobility need assessed as mechanical help. The ISP noted resident ”can move on own without any assistance?. Resident observed on various occasions walking independently in room and throughout the building.
Staff #1 and #2 acknowledged, resident #3 does not require assistance with walking or mobility.

Plan of correction

An update to the UAI will be completed, and quarterly reassessments will be conducted to ensure that the UAI and ISP are aligned with each other Date to be Corrected: February 1, 2025

22VAC40-73-550-G

Based on documents reviewed and staff interviewed, the facility failed to ensure the rights and responsibilities of residents in the assisted living facility was reviewed annually with each resident or his legal representative or responsible individual and each staff person. Written acknowledgement of having been so informed, which shall include the date of the review and shall be filed in the resident’s or staff person’s record.

Evidence

On 12-27-24, resident #2’s record did not include a current review of resident’s rights. Resident’s date of admit noted as 1-24-23.
Staff #5’s record did not include current review of resident’s rights. The last acknowledgment was dated 12-1-23.
Staff #1 acknowledged the resident and staff’s resident rights was not current.

Plan of correction

Resident #2 is under Jewish Family Services and is waiting for her caseworker to come in and sign the necessary papers. However, as per the Licensing person, there is no need to wait for the caseworker, and the resident can sign the papers herself. This will be completed promptly. Date Corrected: January 11, 2025

22VAC40-73-610-D

Based on document reviewed and staff interviewed, the facility failed to ensure when a diet is prescribed for a resident by his physician or other prescriber, it shall be prepared and served according to the physician's or other prescriber's orders.

Evidence

On 12-27-24, resident #1’s blood sugar reading was 288 following the breakfast meal. Resident #1 have a diagnosis of Type 2 Diabetes Mellitus and prescribed Glipizide 5mg twice a day and Metformin 500 mg twice a day. Staff #4 was not able to provide to the inspectors a list or knowledge of the residents who were diabetic and had special diet.
On 12-27-24, resident #1 was served pancakes with syrup. The resident’s record included an order dated 7-9-24 for resident to receive a low sugar mechanical soft diet. Staff #4, the cook for the day, when asked, showed the inspectors the syrup served. Staff stated, “that is what all the residents received, there is no other kind of syrup available”. The syrup that was served to resident #1 was not low sugar nor sugar free.

Plan of correction

Sugar-free syrup was ordered to comply with the resident's diet order. Staff were educated to ensure that the sugar-free syrup is served to residents with the specific diet order first, to avoid mixing it with regular diet orders. New lists have been posted and placed in sleeves to prevent misplacement. Dae Corrected: January 10, 2025

22VAC40-73-660-A

Based on observation and staff interviewed, the facility failed to ensure medication for a resident was stored in a manner consistent with current standards of practice.

Evidence

On 12-27-24, during a tour of the facility and water temperature check with staff #1, Nystatin powder for resident #6 was observed in the resident’s bathroom. Resident #1’s uniformed assessment instrument noted resident is dependent with medication administration. The resident’s record did not have physician’s orders to self-administer medication or keep medication at bedside. The inspector’s previous interviews and observation with resident revealed resident have cognitive concerns.
Staff #1 acknowledged the medication should not have been in the resident’s bathroom.

Plan of correction

To address the issue of improper medication storage, all medications, including ointments, lotions, and powders, will now be kept in the medication cart and only taken when ready to be applied for or used for the resident. A sign will be posted in the medication area to remind staff of this procedure. Additionally, a memo will be sent to all RMAs and CNAs to ensure they understand and comply with the new policy. Supervisors will conduct regular checks to ensure medications are stored and used correctly, and staff will receive ongoing reminders during meetings and training sessions. Corrective action will be completed on January 14, 2025.

22VAC40-73-680-E

Based on document reviewed and staff interviewed, the facility failed to ensure medical procedures or treatments ordered by a physician or other prescribers shall be provided according to his instructions and documented. The documentation shall be maintained in the resident’s record.

Evidence

On 12-27-24, during the medication pass observation with staff #3, resident #1’s blood sugar reading was 288. The resident’s December 2024 medication administration record (MAR) noted ?resident’s blood sugar to be checked and recorded twice weekly 2 hours after meals and notify NPA if blood sugar (BS) reading is > than 180?. Resident’s physician’s order dated 7-29-24 also noted notification if BS greater than (>) 180.
Resident’s clinical notes requested for December 2024 did not include documentation of blood sugar notifications to the physician/nurse practitioner. December 2024 noted BS greater than 180 on 12-13-24 at 1:00 p.m. (226 reading), 12- 13-24 at 6:00 p.m. (217 reading) and 12-23-24 at 9:00 a.m. (191 reading).
The blood sugar read should be taken 2 hours after each meal. The meal hours are noted as 8:00 breakfast, 12:00 lunch and 5:00 dinner. The scheduled time noted on the medication administration record (MAR) for blood sugar check was noted as 9:00 a.m.; 1:00 p.m.; and 6:00 p.m.
Staff #1 acknowledged the facility did not comply with the prescriber’s orders for the resident’s blood sugar time and notification to the physician when reading is greater than (>) 180.

Plan of correction

To address the issue of ensuring timely physician notification for elevated blood sugar results, a label will be attached to each glucometer as a visible reminder for staff to contact the physician when an elevated result is recorded. Staff will be educated on the new procedure, emphasizing the importance of immediately notifying the physician after an elevated reading. Administration will conduct regular spot checks to ensure the labels are properly placed on the glucometers and that staff are following the updated protocol. This new process will be monitored through periodic reviews to ensure compliance and timely communication with the physician. Corrective Action will be corrected ? January 14, 2025 22VAC40-73

22VAC40-73-860-I

Based on observation and staff interviewed, the facility failed to store cleaning supplies and other hazardous materials in a locked area.

Evidence

On 12-27-24 during a tour with staff #1, floor polish material was in a closet in the dining area on the assisted living hallway and not in a locked area.
Staff #1 acknowledged hazardous material was not in a locked area.

Plan of correction

To address the issue of cleaning supplies being exposed and not stored in a locked cabinet, the maintenance and housekeeping staff have been re-educated on the proper storage procedures. Moving forward, all cleaning supplies will be securely stored in a locked cabinet to prevent unauthorized access and ensure the safety of both residents and staff. Staff members will be reminded to verify that the cabinets are properly locked after each use. The day shift in Charge will conduct regular checks and random inspections to ensure compliance with these safety measures. Corrective action will be completed - 01/15/2025.

22VAC40-73-870-E

Based on observation and staff interviewed, the facility failed to ensure all furnishings, fixtures, and equipment, including, window coverings, sinks, toilets, bathtubs, shall be kept clean and in good repair and condition.

Evidence

On 12-27-24, during a tour of the facility with staff #2, the bathroom toilet, floor and walls in room #13 needed cleaning. The kitchen sink in the same room was also in need of cleaning. Residents living in this room, uniformed assessment instrument (UAI) and individualized service plan (ISP) noted residents? dependent in housekeeping instrumental activity of daily living, staff to provide housekeeping services.
Staff # 1 and #2 acknowledged the room was not kept clean.

Plan of correction

To improve cleanliness standards, the weekly cleaning of rooms has been updated to include deep cleaning. This will ensure that all clutter is addressed, and every corner of the room is properly cleaned. Additionally, CNAs will be required to report the cleanliness of each room at the end of each shift to ensure that no areas are overlooked. This process will help maintain a consistently high level of cleanliness and hygiene for the residents. Corrected Action will be completed: January 15, 2025

December 4, 2024Complaint survey6 violations

Inspection dates

Dec. 4, 2024 and Dec. 6, 2024

Areas reviewed

Comments

The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11-27-24 regarding allegations in the areas of staff, buildings and grounds, resident care and related services. Number of residents present at the facility at the beginning of the inspection: 29 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: Number of staff records reviewed: Number of interviews conducted with residents: 8 Number of interviews conducted with staff: 6 Observations by licensing inspector: tour of kitchen with health inspector, temperature check in building Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were valid. A violation notice was issued; any violation(s) not related to the complaint 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-100-C-4

Based on observations and staff interviewed, the facility failed to ensure staff was trained on product specific instructions for use of cleaning and disinfecting agents (e.g. dilution, contact time, and management of accidental exposure).

Evidence

On 12-4-24, the cleaning cloths used to wipe down surfaces were in a bucket of water near the rear door to the kitchen. When asked how long the items were there, staff stated, the cloths are changed every three (3) days. When asked by CC-1 what solution was used to clean the surfaces, staff provided an unlabeled bottle with liquid solution.
Staff acknowledged not knowing the specific requirements for sanitizing surfaces and not knowing the dilution requirements for solutions used for cleaning surfaces in the kitchen.

Plan of correction

Kitchen staff will receive immediate training on the proper dilution ratios for cleaning and sanitizing solutions used in the kitchen. A reference guide with the correct dilution ratios will be posted near the cleaning station for easy access. To ensure compliance with health department guidelines, the cleaning cloths and solutions will be changed every four hours. A documented schedule will be implemented to track the timely replacement of cloths and cleaning solutions. Regular monitoring will be conducted to verify adherence to these procedures. Date of Correction: - January 15, 2025

22VAC40-73-610-C

Based on observation and staff interviewed, the facility failed to ensure the daily menu, including snacks, for each resident shall meet the current guidelines of the U.S. Department of Agriculture’s food guidance system or the dietary allowances of the Food and Nutritional Board of the National Academy of Sciences, taking into consideration the age, sex, and activity of the resident.

Evidence

On 12-4-24, the residents were served one medium pancake, and one linked sausage. The fruit served was two small mandarin segments and three slices of a small strawberry. The eggs served were scrambled, the menu noted fried egg.
Staff # 5and #6 did not respond to the serving sizes provided when asked the proper serving size for the population being served. Staff stated, all food served is provided in advance by management and kitchen staff does not have a key to food supply.

Plan of correction

Staff will undergo re-education regarding the proper serving sizes for each meal component to ensure consistency and adherence to nutritional guidelines. A sample picture illustrating the correct portion sizes will be posted in the kitchen and serving areas as a visual reference for staff. Management will reinforce the importance of portion control, and staff will be reminded that all food servings are pre-determined and provided by the kitchen. Regular checks will be conducted to ensure compliance with the proper serving sizes. Date of Correction: - January 15, 2025

22VAC40-73-610-E

Based on interview, the facility failed to ensure a copy of the diet manual containing acceptable practices and standards for nutrition was kept current and readily available to personnel with responsible for food preparation.

Evidence

On 12-4-24, staff #5 and #6 was not able to provide to the inspector a copy of the facility’s required diet manual.

Plan of correction

Kitchen staff will be re-educated on the importance of having the facility’s required diet manual readily accessible. The location of the manual will be clearly posted in the kitchen for easy access by all staff. Kitchen staff will be trained on where to find the manual and how to use it when needed. Regular checks will be conducted to ensure the manual is accessible and up to day Date of Correction: - January 15, 2025

22VAC40-73-870-D

Based on observation, the facility failed to ensure the building was kept free of infestation of insects and vermin.

Evidence

1 On 12 4 24 in response to a complaint of rodents and roaches in the kitchen an inspection was conducted The
On 12-4-24, in response to a complaint of rodents and roaches in the kitchen, an inspection was conducted. The inspector along with staff #5, #6 and CC-1 observed small black droppings on the stainless steel slicer and off-white colored substance along the wall coving in the back room of the kitchen.
On 12-6-24, the inspector contacted the facility’s pest contractor. The agency, CC-2 provided an invoice dated 11-19-24, which noted ?treatment for the facility cafeteria dining room, kitchen, kitchen stove exhaust and laundry room was treated for German roaches?.

Plan of correction

The facility will continue to schedule monthly pest control visits as planned to ensure a safe and clean environment. These visits will be closely monitored to ensure that all pest control measures are effectively implemented and that any issues are addressed promptly. Date of Correction: - January 15, 2025

22VAC40-73-870-E

Based on observation and staff interviewed, the facility failed to ensure all furnishings, fixtures and equipment was in good repair and condition.

Evidence

On 12-4-24, the stainless refrigerator in the kitchen was observed by the inspector and CC-1 to be wrapped with a blue colored tape and a sign not to open one side. The food in the refrigerator was not holding the required temperature. All food was requested to be discard by the health inspector, CC-1.
Staff stated the refrigerator had been broken for about 3 months. The washing machine and dryer on the residential hallway across from room #21 were working.
The thermostat on the wall near the entrance to the dining room was not working on 12-4-24.

Plan of correction

The broken refrigerator has been temporarily put out of service, and all supplies have been moved to the other refrigerator to ensure there is no disruption in food storage. We are currently waiting for the necessary replacement parts to repair the broken unit. For the dryer issue, a new set of washer and dryer has been added to ensure residents continue to have access to laundry services. Additionally, the thermostat in the lobby area has been replaced to restore proper temperature control. Staff will continue to monitor these areas to ensure all equipment is functioning properly, and necessary repairs will be completed as soon as the parts arrive Date of Correction: January 15, 2025

22VAC40-73-880-B

Based on observations, staff and resident interviews, the heating system in the facility was not working properly. A temperature of at least 72 degrees Fahrenheit was not maintained in all areas used by residents during hours when residents are normally awake.

Evidence

On 12-4-24, the residents and staff stated being cold, staff and residents observed wearing coats. The thermostat on the wall was not working. The moveable thermometer was used to determine the temperature in two areas of the room. The temperature readings were 65.3 F and 66.2 F in the dining room
The temperature in room 51-A was 66.7 and 51-B was 66.0 F.
Space heaters were observed in the kitchen and dining room. Staff informed of the regulation and fire authority requirements for the use of such heating equipment.
On 12-6-24, licensing visit to follow-up on lack of heating on 12-4-24. Rooms 51 A and B continued to have temperature readings under the requirement. A request for the invoice for heating problem requested on 12-5-24 was not provided by staff #1.
A follow-up visit on 12-6-24, CC-3 sent an email while on site , Invoice INV0268 noted, ?Colonial manor No heat call- dining area) No heat call Room 3 No heat call room 51 Found a loose connection on the main limit switch and a dirty flame sensor. Fixed the main limit switch, cleaned the flame sensor, and checked the gas valve gas pressure. Left unit working in proper service. Room 3 and 51 parts have been ordered.
Invoice INV0269 received from CC-3 on 12-7-24 noted, room #3 system in the center, not working, 2-ton system in middle of room with a burn up 24v transformer, broken overflow switch, and a shorted wire inside the condenser unit. Fixed problem. Room #51, blower motor not running, bad blower motor capacitor, capacitor replaced.
The Accu-Weather Temperature for 12-4-24 was a High (H) of 46 degrees Fahrenheit (F) with a low (L) of 19 degrees. The temperature on 12-5-24 (51-H/ 28-L); 12-6-24 (40-H/20-L and 12-7-24 (44-H/17-L).

Plan of correction

An HVAC company was contacted to address the complaint regarding heating issues in certain areas of the facility. Necessary parts were replaced immediately, and additional parts are being ordered to complete the repairs. Once all parts are received, the HVAC company will return to finalize the work. Staff will monitor the affected areas to ensure proper heating until the repairs are fully completed. Date of Correction: December 8, 2024

November 22, 2024Inspection14 violations

Inspection dates

Nov. 22, 2024

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments

Type of inspection: Monitoring An unannounced monitoring inspection conducted on-site on November 22, 2024. (Ar 08:00 a.m./ dep 15:10 p.m). The administrator was not present when inspectors arrived, did come to the facility later. Not present for the exit meeting, participated via telephone. 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: 31 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 3 Number of staff records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: breakfast/lunch meal; medication review; tour of facility with staff Additional Comments/Discussion: 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at Willie.barnes@dss.virginia.gov

Violations

22VAC40-73-110-1

Based on an attempted interview and other staff interviewed, the facility failed to ensure staff was able to speak, read, and understand in English as necessary to carry out their job responsibilities.

Evidence

On 11-22-24, the inspector went to speak to a new staff member who was performing housekeeping duties in the hallway near the dining area. Staff #5 stated not able to speak English. Staff #7 was updating the dietary staff board nearby and came over to inform the inspector that staff #5 did not speak English. Staff #7 was asked how could staff #5 communicate with the residents if staff did not speak English. Staff 7 stated staff #5 uses a translator.
The inspector spoke with Staff #2 regarding staff #5’s inability to speak in English. The inspectors were informed by staff #2 that staff #5 should have had the telephone that is used as a translator for the employee. Staff #2 also informed the inspectors of staff #5’s enrollment in a class to learn how to speak English.
Staff #2 was shown the standard regarding staff qualifications included being able to speak English. The staff’s job duties assigned were server and housekeeping. The facility dietary bulletin board noted staff #5 worked as a server on 11- 19-24. The dietary schedule noted staff #5’s first day of work 11-6-24. The housekeeping schedule noted first day of work 11-4-24. Staff #5’s record noted staff’s date of hire and orientation as 11-1-24.

Plan of correction

Staff #5 was hired with limited English proficiency, so she is enrolled in an English as a Second Language (ESL) class. Proof of enrollment was presented and submitted during the inspection. She complies with her work and is thorough in her job. She also carries a cell phone as a form of communication while still learning the language. She uses a translation app on her phone.

22VAC40-73-150-F

Based on document reviewed and staff interviewed, the facility failed to ensure the facility licensed for both residential and assisted living cared, the administrator served on a full-time basis as the on-site agent of the licensee and shall be responsible for the day-to-day administration and management of the facility.

Evidence

On 11-22-24, the ?Admin Schedule dated October 20, 2024, to November 30, 2024, noted the following hours for staff #1: (a) Week 10-20-24 to 10-26-24 noted 26 hours. (b) Week 10-27-24 to 11-2-24 noted 24 hours. (c) Week 11-3-24 to 11- 9-24 noted 16 hours. (d) Week 11-10-24 to 11-16-24 noted 14 hours.
Staff #1 was reminded of the standards regarding full-time requirements for the administrator.

Plan of correction

Staff#1's hours will be submitted weekly to Staff #2. This will include weekend hours to comply with the full-time requirement. Corrected Date: ONGOING - January 10, 2025

22VAC40-73-320-A

Based on document reviewed, the resident’s physical examination shall not have any of the conditions or care needs prohibited by 22VAC40-73-310-H.

Evidence

On 11-22-24, resident #1’s physical examination signed and dated 10-8-24 by an independent physician noted the resident needs requiring continuous licensing nursing care was checked as Yes. (22VAC40-73-310-H.9)
Staff #2 acknowledged the documentation need to be corrected.

Plan of correction

Resident #1's admission note was revisited and updated by the current physician. It was also noted in the physical exam that the admission note was revised by the physician currently handling resident's care.

22VAC40-73-450-F

Evidence

On 11-22-24, resident #2’s uniformed assessment instrument (UAI) dated 7-23-24 note resident was independent with dressing need. The ISP dated 7-24-24 noted resident required human help with physical assistance. Services to be provided by facility staff and resident, choose clothing, staff assist in putting on clothes, and socks, buckling off top underwear, and buttoning shirt when needed. Stairclimbing need on UAI noted mechanical help only, the ISP noted mechanical help with physical assistance. Resident will need assistance with climbing stairs or climbing a van, resident to hold on the handrails. Behavior pattern need noted as appropriate on the UAI. The ISP noted abusive/aggressive/disruptive behavior less than weekly. When resident becomes agitated, staff will attempt to redirect resident or re-approach at another time. Activities of interest will be held to limit resident’s agitation. Medication will be provided when necessary to calm resident down.
Staff #2 acknowledged the resident’s UAI and ISP did not agree.

Plan of correction

Resident #2's UAI was completed by a case worker who does not observe the resident's daily routine. Staff #2 contacted the case worker to correct the UAI. This was done immediately, and it was agreed to schedule an evaluation the next times the UAI is completed.

22VAC40-73-550-G

Based on documents reviewed, the facility failed to ensure the rights and responsibilities of residents in the assisted living facility was reviewed annually with each resident or his legal representative or responsible individual. Written acknowledgement of having been so informed, which shall include the date of the review and shall be filed in the resident’s record.

Evidence

On 11-22-24, resident #2 and #3’s resident’s right was last reviewed on 10-6-23. There were nineteen (19) other residents in the facility whose resident’s right was not updated since 10-6-23. One resident’s right was last dated 10-21- 23 and another 9-21-23. The facility census was noted as 31.
Staff #2 acknowledged the residents? rights were not reviewed annual as required.

Plan of correction

Resident #2 and #3's Residents' Rights and Responsibilities forms were completed. As part of the CAP, the Administrator's Assistant added another monthly review forms to prevent this from being missed again.

22VAC40-73-650-A

Based on record reviewed and staff interviewed, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications.

Evidence

On 11-22-24, resident #1’s record did not have a signed and dated prescriber’s order for the Amlodipine Besylate 5mg and Pantoprazole 20 mg medications signed off on the November 2024 medication administration record.
Staff #3 searched for the prescriber’s orders but did not locate any. Staff acknowledged the facility did not have prescriber’s orders for resident #2’s Amlodipine Besylate 5mg and Pantoprazole 20 mg.

Plan of correction

Corrected- will assign another person to review the order. The order was sent to the pharmacy directly and requested a copy of the prescription.

22VAC40-73-650-B

Based on document reviewed and staff interviewed, the facility failed to ensure physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall include and identify the diagnosis, condition, or specific indications for administering each drug.

Evidence

On 11-22-24, resident #1’s record noted resident prescribed Candesartan Cilexetil 4mg and Spironolactone 25 mg. The admitting physical examination dated 10-8-24 did not include a diagnosis, condition, or specific indication for these medications. The resident’s crush order dated 11-15-24 also noted these medications but there was no diagnosis noted.
Staff #2 and #3 acknowledged the resident’s prescriber’s orders did not include or identify the diagnosis, condition, or specific indications for administering the aforementioned drugs being administered.

Plan of correction

Reminders have been sent to the doctors about the importance of including diagnosis in their orders. A reminder was also sent to the pharmacy to ensure alignment with regulations.

22VAC40-73-680-C

Based on record reviewed and staff interviewed, the facility failed to ensure medications shall 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

On 11-22-24, resident #3’s November 2024 medication administration record (MAR) noted the following medications administered outside of the dosing schedule: (a) 11-2-24, 8:00 a.m. medications given at 09:23. (b) 11-3-24 to 11-5-24, 7:00 am medications given at 08:42; 08:28; and 09:24. (c) 11-5-24, 08:00 am medications given at 09:24. (d) 11-8-24, 08:00 medications and 08:30 medications given at 09:51. (e)11-9-24, 7:00 p.m. medications given at 8:37 p.m. (f) 11-10- 24, 7:00 p.m. medications given at 8:17 p.m. (g) 11-12-24, 8:00 a.m. medications given at 09:38. (h) 11-14-24, 08:00 and 08:30 a.m. medications given at 2:56 p.m. (i) 11-20-24, 08:00 a.m. medications given at 09:27 a.m. (In November 2024, resident #1 was administered prescribed medications, 9 days outside of the dosage schedule). Resident #1 was administered 4 prescribed medications, 5 days outside of the dosage schedule. Resident #2 was administered 10 prescribed medications 4 days outside of the dosage schedule.

Plan of correction

The administrator will implement a corrective action plan to ensure that medications are charted on time. The plan includes setting clear deadlines for charting, providing training to staff on the importance of timely documentation, and conducting regular audits to monitor compliance. Any delays will be addressed promptly through follow-up meeting and additional support as needed.

22VAC40-73-680-E

Evidence

On 11-22-24, resident #2’s November 2024’s medication administration record (MAR) noted the resident ?Ted Knee Hi BGE XL Reg,“ was to be put on every morning and off at bedtime for Edema **XL (extra-large) open toe knee high”. The MAR noted the item was signed off as completed on 11-22-24. Resident #2 was observed in the dining room having on a pair of white above the ankle’s socks. Physician’s orders dated 11-5-24 noted resident’s Ted Knee Hi -open toe knee high.
Staff #3 was not able to locate resident’s Chlorthalidone 25 mg, Feminine body wash and Nystatin topical powder, 8:00 a.m. medications that was noted on the November 2024 MAR and was signed off on 11-22-24 as administered. Staff went to resident’s room to locate the Feminine wash as it was stated it is kept in the room. There is no order for this item to be kept in the room. Staff #3 stated Feminine Wash was not in resident’s room.
Staff #3 acknowledged all resident #2’s medical needs noted on the November 2024 medication administration record were not available in the facility.

Plan of correction

RMA will ensure that Resident receives her TED hose stockings as prescribed. Additionally, the feminine wash will now be kept in the nurse station, and Care Aide will collect it from the nurse station each day to administer the first wash of the day.

22VAC40-73-680-M

Based on document reviewed and staff interviewed, the facility failed to ensure the medication administration record (MAR) included all required information.

Evidence

On 11-22-24, resident #2’s November 2024 mar did not have initials of the direct care staff administering the following medications: (a) Levothyroxine 0.025 mg on 11-5-24 at 6:00 a.m. is blank. (b) Oxygen at 2liter/minute via nasal cannula on 11-28-24 at 12:00 a.m. is blank and 11-9-24 and 11-10-24 at 7:00 p.m. is blank. (c) Ted Knee High at 8:00 a.m. is blank on 11-2 to 11-4-24 and 11-16 to 11-17-24.
Staff acknowledged the resident’s MAR did not include signatures of staff.

Plan of correction

22VAC40-73-860-I

Based on observation and staff interviewed, the facility failed to ensure it stored cleaning supplies and other hazardous materials in a locked area.

Evidence

On 11-22-24, during a tour with staff # 4, the cleaning cart containing household chemicals, cleaning chemicals was left unlocked and unattended in the hallway near room #20 and #21.
Staff #6 came out of the room and took cart after being informed of the unlocked, unsupervised cart with chemicals.
Staff #4 acknowledged the cart contained hazardous materials and was not locked and not supervised.

Plan of correction

Housekeeping staff have been retrained to ensure the cart is not left unlocked when entering a room to clean, and they will be reminded to securely store the cart at all times when not in use.

22VAC40-73-870-A

The facility failed to ensure the interior of all buildings was maintained in good repair and kept clean and free of rubbish.

Evidence

On 11-22-24, the exit door near the vending machine, used by residents to exit to the smoking area was in need of repair. Only one door can be opened due to the ground shift/raising and prevents the door to the right from being opened without force.
Staff #3 acknowledged the door was in need of repair.

Plan of correction

Exit door access has been completed. The tree root that was growing towards the door was addressed, and maintenance resolved the issue by removing the root and resealing the area to ensure proper access for the residents.

22VAC40-73-870-E

The facility failed to ensure the toilet, bathtub, showers was kept clean and in good repair and condition.

Evidence

On 11-22-24, the cut out-step-in entrance to the shower in room #52 is missing tiles.
The toilet in the proposed safe, secure dining area is not working and is missing a toilet seat. This violation was cited 10-30-24, no change or repair made.
Staff #3 acknowledged the areas in need of repair.

Plan of correction

A work request was submitted, and maintenance has completed the necessary repairs. This toilet is not currently in use. It has been included in the work request for maintenance to repair.

22VAC40-73-880-B

Based on observation and interview the facility failed to ensure it allow the temperature in a bedroom in which resident Description: Based on observation and interview, the facility failed to ensure it allow the temperature in a bedroom in which resident resides, which has a thermostat in the room, to be controlled by the resident as long as the temperature does not endanger the health, safety, or welfare of the resident.

Evidence

On 11-22-24, resident stated being cold and not able to change the temperature in room to make it warmer.
A check of the room determined the facility had a lock on the thermostat and resident could not change the temperature.
Staff #3 was present in room #27 and acknowledged that the thermostat’s in the resident’s room was locked.
Staff #1 acknowledged having a lock on the thermostats in the resident's rooms in the facility during the exit meeting.

Plan of correction

The HVAC company came and repaired the system in every room, including the hallways and dining area. Additional supplies are being ordered, and repairs will be scheduled once the supplies arrive.

October 30, 2024Inspection4 violations

Inspection dates

Oct. 30, 2024

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

Comments

Type of inspection: Monitoring An unannounced monitoring inspection was conducted. The focus of the inspection was to determine whether the provider had corrected or is in the process of correcting previously cited violations in the areas of standards referenced above. Any non-compliant elements of law or regulations are documented in the Violation Notice of this inspection. This inspection found the provider to demonstrate noncompliance with standards not identified in the plan of correction. An unannounced monitoring inspection was conducted on 10-30-24 with two inspectors from the Peninsula Licensing Office. The facility census was 30. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-450-F

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for three of three resident’s record reviewed.

Evidence

On 10-30-24, resident #1’s ISP dated 12-12-23 noted, ?Physical therapy twice a week out of the facility...start date 5/23/2024 End date is blank. Occupational therapy 1-2 x per week at the facility start date 5/21/2024 End date is blank.? Staff #2 and #3 stated resident no longer participates in occupational and physical therapy. No outcome achieved date noted on the ISP. The ISP not updated with signature of resident and developer to indicate this change of service which started in May 2024, physician’s order dated 5-15-24. The ISP was last signed and dated by resident and developer 12-12-23.
Resident #2’s uniformed assessment instrument (UAI) dated 2-5-24 noted dressing assessed as human help/supervision. The ISP dated 2-5-24 and updated 5-3-24 noted, ?staff will also help with buttoning and zipping. If needed and prompt on what to do next.?
Resident #3’s ISP dated 10-2-24 noted yes for housekeeping need. The ISP noted, ?resident will receive housekeeping services on a scheduled basis dependent upon need or PRN for accidents?. The plan did not include when the services would be provided. The ISP noted for bowel and bladder need, ?resident will be supervised when changing adult diapers and assist as needed. The resident is assessed as on the UAI dated 10-2-24 as being totally dependent on staff to perform all services.
Staff #2 and #3 acknowledged the aforementioned resident’s ISP did not include all required information.

Plan of correction

Resident #1's ISP did not reflect discontinued therapy services and lacked updates and signatures. Resident #2’s ISP did not fully address dressing assistance, and Resident #3's ISP lacked details on housekeeping timing and bowel/bladder care. The facility immediately updated all three ISPs with accurate information and services and used proper wording. Moving forward, ISPs will be reviewed regularly, and staff will be retrained to ensure all updates are timely and complete. These actions will be monitored to prevent future issues. Date of Correction: October 30, 2024

22VAC40-73-860-D

Based on observations and staff interviewed, the facility failed to ensure any operable window (i.e. a window that may be opened) was effectively screened.

Evidence

1 On 10 30 24 during a tour of the facility with staff #1 #3 and #4 the windows in room #49 #41 and the Activity room
On 10-30-24 during a tour of the facility with staff #1, #3 and #4, the windows in room #49, #41 and the Activity room across from room #37 was not effectively screened.
Staff #1 acknowledged the aforementioned rooms did not have screens.

Plan of correction

The maintenance team will immediately install or repair screens on the affected windows and ensure that all operable windows throughout the facility are properly screened. Moving forward, the maintenance staff will conduct regular checks to ensure that all screens are in good condition. Date of Correction: December 1, 2024

22VAC40-73-870-E

Based on observations and staff interviewed, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition.

Evidence

On 10-30-24 during a tour of the facility with staff #1, #3 and #4, the toilet in room #31 did not have a top on the tank and the water was also heard to be constantly running. The toilet in the bathroom in the dining area on the proposed safe secure unit was not working and did not have a top on the seat.
Staff #3 acknowledged the toilets were not in good condition.

Plan of correction

This issue was corrected same time that it was discovered. Maintenance staff addressed the problem a week ago by repairing the toilets and ensuring they are now in good working condition. Moving forward, maintenance will continue to monitor and inspect all fixtures to ensure they remain clean, functional, and in good repair. Date Corrected: October 30, 2024

22VAC40-80-120-E-3

Based on observation and staff interviewed, the facility failed to ensure it was in compliance with the terms of the license.

Evidence

On 10-30-24, the facility did not have the “Notice of Intent/ NOI” posted in the facility in a prominent place at each public entrance of the facility to advise consumers of serious or persistent violations. This is a repeat violation from 9-25- 24 inspection.
Staff #2 acknowledged the NOI document was not posted as required by the terms of the license.

Plan of correction

The NOI was immediately posted in a prominent location at the entrance for public view. This will be in a lock bulletin board. Date of Correction: October 30, 2024

September 25, 2024Inspection6 violations

Inspection dates

Sept. 25, 2024

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE

Technical assistance

Resident Agreement- Disclosure and Resident Handbook information differs in each document, inconsistent information. Facility not licensed as memory care as noted in documents. Facility noted as Independent Facility.

Comments

Type of inspection: Monitoring An on-site mandated monitoring was conducted on 9-25-24, the LA from the PLO was present. Ar 07:30 a.m./dep 16:10 p.m. Facility census was 32.. Administrator was not present for exit meeting. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-310-H

Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with psychotropic medical condition without a diagnosis and treatment plan for two of three records reviewed.

Evidence

On 9-25-24, resident #1’s record included a physician’s order electronically signed on 9-5-24 for Hydroxyzine (Atarax). The resident’s record did not include a psychotropic treatment plan for this psychotropic medication.
On 9-25-24, resident #3’s record included a signed and dated physician’s order dated 7-16-24 for Wellbutrin XL 150 mg at bedtime. The resident’s record did not include a psychotropic treatment plan for this psychotropic medication.
Staff #2 and #3 acknowledged the residents? record did not include a psychotropic treatment plan for the prescribed psychotropic medication.

Plan of correction

The facility will fix the issue by updating the records for Resident #1 (10/16/2024) and Resident #3 (7/24/2024 ) to include signed treatment plans for their psychotropic medications. Monthly audits will be conducted for three months to check compliance with these changes. Date Corrected: 10/16/2024

22VAC40-73-450-C

Based on record reviewed and staff interviewed, the facility failed to ensure that the resident’s individualized service plan Based on record reviewed and staff interviewed, the facility failed to ensure that the resident’s individualized service plan (ISP) included all assessed needs for one of three records reviewed.

Evidence

On 9-25-24, resident #1 was observed walking independently throughout the facility. Resident’s uniformed assessment instrument (UAI) dated 9-5-24 and completed by staff #3 and signed and dated by staff #2 documented walking and mobility need assessed as mechanical help (mh). The resident’s individualized service plan (ISP) dated 9-5-24 and completed by the same staff members documented walking need, mechanical help, ?resident holds handrail and a cane in the hallway while walking to support?“. Mobility needs documented, mechanical help, ” resident will be using a cane and side rail to move in/out of “quarters while walking in the hallway.”
Staff #2 stated resident does not need cane to walk, staff #3 showed staff #2 the resident’s ISP noted resident’s use/need for a cane while walking.

Plan of correction

The individualized service plan (ISP) for Resident #1 was initially created upon admission, and the team is still gathering information about the resident's specific needs. As such, the ISP and the uniformed assessment instrument (UAI) have been updated after 30 days to reflect the resident’s current mobility requirements. The updated UAI and ISP now accurately document that the resident does not require a cane for walking, based on further observation and assessment. Staff will receive training on the importance of regularly reviewing and updating ISPs to ensure they fully reflect each resident’s needs. Regular audits will be conducted to ensure all ISPs are current and comprehensive. Date Corrected: 10/3/2024

22VAC40-73-650-B

Based on document reviewed and staff interviewed, the facility failed to ensure the physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements included the diagnosis, condition, or specific indications for administering each drug.

Evidence

On 9-25-24, resident #1’s physician orders dated 8-16-24 did not include the diagnosis, condition, or specific indications for the following medications: (a) Amlodipine 10 mg, (b) Aspirin 81mg, (c) Atorvastatin 40 mg, (d) Cholecalciferol 10,000 units, (e) Citalopram 20mg, (f) Losartan 100mg, (g) Hydrochlorothiazide 12.5 mg, (g) Mirtazapine 15 mg, (h) Polyethylene glycol 17 g, (i) Senna-Docusate 8.6-50 mg, (j) Vitamin B-1 and (k) Vitamin B6.
Staff #2 and #3 acknowledged the resident’s physician’s order did not include the diagnosis for medications prescribed.

Plan of correction

The physician orders for Resident #1 were based on information provided by the hospital before discharge. As this is a new admission, the facility is currently awaiting the new Primary Care Physician (PCP) to rewrite the orders to include the required diagnoses for each prescribed medication. In the meantime, staff have been instructed to follow up with the PCP's office to expedite this process. Additionally, staff were educated on the importance of including diagnosis and indications in medication orders to ensure compliance moving forward. Regular audits will be implemented to verify that all future orders include necessary diagnostic information. Date Corrected: 11/10/2024

22VAC40-73-680-K

Evidence

On 9-25-24, during the medication pass observation with staff #3, resident #2’s morning medication noted Polyethylene Glycol/Miralax Powder was to be given at 8:00 a.m. The document also noted the medication was prescribed for seven (7) days as a PRN, mix 17 grams in 8-16 ounces of liquid. The physician’s order dated 8-1-24 documented, “17 g in 8-16-oz water. Oral PRN ”.?.
Staff #3 acknowledged the PRN dosage was 8-16-oz water and not an exact amount.

Plan of correction

The facility will ensure that all PRN medication orders include exact dosages, symptoms for use, and specific instructions. Staff have been instructed to refuse any orders lacking this information. Regular audits will be conducted to ensure compliance, and staff will be encouraged to ask questions about unclear orders. Date Corrected: 10/25/2024

22VAC40-73-870-A

Based on observation, resident and staff interviewed, the facility failed to ensure the facility was maintained in good repair and kept clean and free of rubbish.

Evidence

On 9-25-24 during a tour of the facility with staff #3 and #4, resident in room #14, informed staff of a leak in room and water on floor. Upon entering the room, there was a wet white towel on the floor near entrance. The resident was using the towel to mop up the water. Water was observed on the floor from the door entrance to the kitchen area. Staff and resident were not able to determine where the water was coming from.
Staff #3 and #4 acknowledged the resident’s room floor was flooded with water and unable to determine where the water was coming from.
On 9-25-24, the inspector tried to open to door to the conference room that leads into the living area of the building. The upper hinge to the door was not working. Staff #3 opened the door and acknowledged; the door hinge was not working properly.
Staff #3 and #4 acknowledged the building areas mentioned above were not in need of repair.

Plan of correction

The facility will improve maintenance by hiring a new maintenance person who will be on-site five days a week to address repairs and ensure the building is well-managed. Following the recent observations of a leak in resident room #14 and a malfunctioning door hinge in the conference room, the new maintenance staff will prioritize these issues. They will investigate the source of the water leak and implement necessary repairs promptly. Regular inspections will also be conducted to ensure the facility remains clean and in good repair. Staff will be trained to report any maintenance issues immediately. Date Corrected: 10/1/2024

22VAC40-80-120-E-3

Based on observation and staff interviewed, the facility failed to ensure it was in compliance with the terms of the license.

Evidence

On 9-25-24, the facility did not have the “Notice of Intent/ NOI” posted in the facility.
Staff #2, #3 and #4 acknowledged the required Notice of Intent/NOI was not posted in the facility as required.

Plan of correction

The NOI has been reprinted and prominently posted in the designated binder, accompanied by a clear note instructing staff not to remove it. Staff were reminded of the importance of maintaining regulatory compliance through a training session, reinforcing this requirement Date Corrected: 9/25/2024

August 23, 2024Inspection10 violations

Inspection dates

Aug. 23, 2024

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments

Type of inspection: Monitoring An on-site non-mandated monitoring inspection was conducted on 8-23-24. (Ar 10:22 a.m./Dep 14:40 p.m.) 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: 31 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-250-C

Based on record reviewed and staff interviewed, the facility failed to ensure it verified staff had received a copy of current job description.

Evidence

On 8-23-24, interview with staff #6, revealed one of staff’s dietary job was a cook. The job description for cook in the record was not signed.
Staff #2 and #3 acknowledged the aforementioned staff did not verify receiving job description for cook.

Plan of correction

On August 23, 2024, the cook signed the job description immediately upon realizing the oversight. To prevent this issue in the future, the facility will verify that every page of job descriptions is signed and acknowledged by staff. Date Corrected: August 23, 2024

22VAC40-73-250-D

Evidence

On 8-23-24, staff #6’s TB document was observed to have a date that was written over. The date on the document written with the same ink as the staff’s name, date of birth and first digit of the date of the screening was noted as 8-17-
The staff’s date of hire in the record, noted on the orientation document was noted as 8-12-24.

Plan of correction

The nurse responsible for the TB assessment immediately corrected the issue. To prevent similar occurrences in the future, the nurse will type the date to ensure legibility. Additionally, the Assistant Administrator has instructed nurses to place a line through any errors, dates, and initial corrections to avoid this issue from happening again. Date Corrected: August 23, 2024

22VAC40-73-380-A

Based on record reviewed and staff interviewed, the facility failed to ensure it obtained all the required personal and social information.

Evidence

On 8-23-24, the resident #1’s record did not include the resident’s previous mental health or intellectual disability services, if applicable for care needs; current behavioral and social functioning including strengths and problems; and any substance abuse history if applicable for care or services.
Staff #1 and #2 acknowledged the resident’s record did not include all required personal and social information for care or services.

Plan of correction

The Assistant Administrator immediately addressed the issue by updating the social data form. To prevent this from happening again, the facility will ensure that all required personal and social information is collected and documented as part of the corrective action plan. Date Corrected: August 23, 2024

22VAC40-73-410-A

Based on record reviewed and staff interviewed, the facility failed to ensure it had written acknowledgement of having provided orientation to a resident and having signed and dated the document and a copy kept in the resident’s record.

Evidence

On 8-23-24, resident #1’s record did not have documentation of having receiving orientation to the facility.
Staff #1 and #2 acknowledged the resident’s record did not include written acknowledgement of having received orientation to the facility.

Plan of correction

The issue was immediately addressed. The Assistant Administrator updated the form to include signatures and dates for new residents. Additionally, RMAs were educated to use dates in each category on the form rather than just check marks to ensure comprehensive documentation in the future. Date Corrected: August 23, 2024

22VAC40-73-610-D

Based on record reviewed and staff interviewed the facility failed to ensure the prescribed diet for a resident is prepared Description: Based on record reviewed and staff interviewed, the facility failed to ensure the prescribed diet for a resident is prepared and served.

Evidence

On 8-23-24, resident #1’s physical examination dated 7-18-24 noted the resident’s prescribed diet of 3 grams of sodium. The dietary staff #6 did not have a copy of the resident’s diet order in the kitchen.
Staff #1 and #2 acknowledged the resident’s diet order was not being prepared as prescribed by the physician.

Plan of correction

The issue was immediately addressed by faxing a new diet form to the physician and requesting a revised order without specific sodium grams. The facility will ensure that all dietary orders are properly documented and accessible to kitchen staff to prevent future occurrences. Date Corrected: August 23, 2024

22VAC40-73-610-E

Based on staff interviewed, the facility failed to ensure a copy of the diet manual containing acceptable practices and standards for nutrition was kept current and readily available to personnel responsible for food preparation.

Evidence

On 8-23-23, during a tour of the kitchen, staff #6 was not able to provide a copy of the diet manual. Staff stated not being aware of such a book since being hired. Staff #6’s date of hire noted as 8-12-24. Staff stated job was that of the cook/server.
Staff # 6 acknowledged not having or knowing about the diet manual.

Plan of correction

The issue was immediately addressed by relocating the diet manual to a more accessible location in the kitchen. The manual was reviewed with staff, including new hires, to ensure they are aware of and can easily access the document in the future. Date Corrected: August 26, 2024

22VAC40-73-750-B

Based on observation, resident interviewed, and staff interviewed, the facility failed to ensure a resident’s bedroom had window covering for privacy.

Evidence

On 8-23-24, during a tour of the facility with staff #4, resident #3’s room (#14) was observed to not have window covering. Resident stated a preference for blinds verses curtain for privacy.
Staff #1 and #4 acknowledged resident #3’s room, #14 did not have window coverings for privacy.

Plan of correction

Window blinds were promptly installed in resident #3’s room. Additionally, maintenance has been assigned to conduct monthly inspections to ensure that all rooms have appropriate window coverings and to prevent this issue from occurring again. Date Corrected: August 26, 2024

22VAC40-73-870-A

Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair and kept clean and free of rubbish.

Evidence

On 8-23-24 during a tour of the facility with staff #4 and later with staff #1, the hallway door near room #39 and #40 did not have a doorknob. Resident #3’s room #14, the window screen was in need of repair, the thermostat in the entrance hallway was not working. The door to the AC unit was observed to have a buildup of grey substance on the door. The air filter was in need of cleaning/changing; observed to have a heavy buildup of dark-greyed colored substance.
The window in the Activity room across from room #37 was observed to have a large cobweb developing. Several slats/vents on the door to the AC unit were missing and broken.
The baseboard located at the entrance to the purposed safe, secure unit, near the beauty salon was observed to be in need of repair. The doorknob on the door to the entrance of the unit fell off when turned.
In room #18, the slats/vents on the door to the AC unit were missing and broken. The filter for the AC unit was observed to be bent and have a buildup of dark grey colored substance.
Staff #1 acknowledged the aforementioned areas were in need of repair.

Plan of correction

The facility has addressed the issues by installing a new doorknob on the hallway door near rooms #39 and #40 and repairing the doorknob and baseboard at the proposed safe, secure unit near the beauty salon entrance. The damaged window screen in resident #3’s room (#14) will be replaced, and the large cobweb was removed from the Activity Room window. The malfunctioning thermostat in the entrance hallway was not broken- the battery has been replaced, and the AC unit door, including its slats/vents, was cleaned and repaired. The heavily soiled air filters in resident #18’s room and elsewhere will be replaced, awaiting the shipment of all the filters. A routine maintenance schedule has been established for regular inspections, and the lock and filters have been ordered and will be installed upon arrival. Date Corrected: September 30, 2024

22VAC40-73-870-E

facility failed to ensure all furnishings, fixtures and equipment, including furniture, window coverings, sinks, toilets, esc pt o : ets, bathtubs, and showers shall be kept clean and in good repair.

Evidence

On 8-23-24 during a tour of the facility with staff, #1 and #4, the bathtub in room #14 was observed to have tanned colored area near the tub faucet. The faucet had a continual dripping, unable to turn off. The toilet bowl was observed to have tan/brown colored stains.
Staff #1 acknowledged the aforementioned areas were in need of repair or cleaning.

Plan of correction

The faucet and bathtub in room #14 have been repaired. The toilet bowl will be replaced to address the stains. Date Corrected: September 6, 2024

22VAC40-73-990-C

Evidence

On 8-23-24, staff #2 provided the inspector with the resident emergency practice sign in sheet dated 5-16-24. The document did not include the signatures of all staff employed.
Staff #2 acknowledged all staff members on each shift did not participate in the resident emergency practice as required

Plan of correction

facility will schedule an additional emergency practice session for this year to ensure compliance with the regulation and that all staff participate as required. Date Corrected: September 30, 2024

July 30, 2024Inspection2 violations

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments

Type of inspection: Monitoring An on-site unannounced non-mandated monitoring inspection was conducted on 7-30-24. (Ar 07:25 a.m/Dep 11: 55 a.m.) 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: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. yes Number of resident records reviewed: 2 Number of staff records reviewed: 3 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 7 Observations by licensing inspector: Additional Comments/Discussion: 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-450-F

Based on record reviewed and staff interviewed, the facility failed to ensure that the resident’s individualized service plan (ISP) included all assessed needs for a resident.

Evidence

On 7-30-24, resident #1’s document in record, “Patient Clinical Summary” dated 8-8-23 noted the following allergies: (a) All Cillins- mild-unknown, (b) Penicillin- critical- unknown and (c) Tuna- moderate- nausea. A document, ?Active Medication List? from the resident’s local medical agency with fax date 11-7-23 noted the following allergies: (a) Penicillin G, (b) Augmentin Amoxicillin Trihydrate, (c) Augmentin Potassium Clavulanate and (d) Trazodone. The resident was observed using a cane for ambulation. The record included documentation from physical therapy note from the current agency providing home health services noting the need for resident to “use a cane for all ambulation”. The resident’s uniform assessment instrument (UAI) dated 4-18-24 noted walking and stairclimbing assessed as mechanical help. The individualized service plan dated 4-18-24 noted walking with handrails. The cane use was not documented on the resident’s ISP. The resident’s fall assessment dated 3-24-24 noted the resident assessed as high risk, the ISP noted the resident at a low risk for falls. The resident’s individualized service plan (ISP) dated 4-17-24 did not include all assessed needs.
Resident #2’s document in record, “Visiting Physicians Association” dated 4-19-22 noted resident allergic to Drug- Penicillins, Pollen, and no known food allergies. The resident’s ISP dated 11-3-23 did not include the pollen allergy.
Staff # 1 and #3 acknowledged the residents? ISP did not include all assessed needs.

Plan of correction

The issues identified with Resident #1’s and Resident #2’s records have been addressed. The Individualized Service Plan (ISP) will be thoroughly reviewed and updated to accurately reflect all documented needs and allergies. Specifically, the ISP will now include the correct documentation of allergies, mobility aids, and fall risk assessments for Resident #1, and the pollen allergy for Resident #2. To prevent future discrepancies, all physician orders will be verified by two additional personnel to ensure completeness and accuracy. Date Corrected: July 30, 2024

22VAC40-73-870-E

Evidence

On 7-30-24, during the breakfast meal observation, the windowsills in the dining room were observed to need cleaning. The vents for the two window air conditioners were observed to have a heavy build up of a grey substance on the vents.
Staff # 5 and #6 were shown the windowsills and the air conditioner vents and acknowledged, the area and vents needed cleaning.

Plan of correction

On July 30, 2024, issues were identified with cleanliness in the facility, including dirty windowsills and air conditioner vents with grey buildup. Immediate actions included cleaning these areas and training staff on proper cleaning procedures. Long-term measures involve establishing a regular cleaning schedule and assigning staff to monitor cleanliness. Regular audits will be conducted to ensure ongoing compliance, with all actions documented and reviewed periodically to ensure effectiveness. Date Corrected: July 30, 2024

June 28, 2024Inspection6 violations

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments

Type of inspection: Monitoring An on-site unannounced mandated monitoring conducted on 6/28/24 by two inspectors from the Peninsula Licensing Office. Ar (07:56 a.m./ Dep 13:50 p.m.). The facility census was 30. 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: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-70-C

Based on staff interviewed, the facility failed to ensure that it submitted a written report of each incident to the regional licensing office within seven days from the date of the incident. The report shall be signed and dated by the administrator and include all required information.

Evidence

On 6-18-24, staff #1 reported by telephone an incident (death) of resident #4. The facility did not provide the licensing inspector with a written report within seven days.
On 6-28-24, staff #1 acknowledged not providing the licensing office with the required written incident report in accordance with the regulation and the facility’s policy and procedures reporting of incidents.

Plan of correction

To address the issue of delayed incident reporting, the facility will immediately update procedures to ensure all incidents, including deaths, are properly documented in our computer charting systems. This will streamline reporting incidents to the appropriated personnel responsible for creating and submitting the required written reports to the licensing office within seven days. Staff will receive additional training on utilizing the computer charting system for incident reporting to ensure accuracy and efficiency. Regular audits will be conducted to monitor compliance with these updated procedures.

22VAC40-73-450-E

Based on document reviewed and staff interviewed, the facility failed to ensure the individualized services plan (ISP) was signed and dated by the licensee, administrator, or his designee, and by the resident or the legal representative.

Evidence

On 6-28-24, resident #1’s ISP dated 6-8-23 and 7-8-23 was not signed and dated by the resident’s legal representative. The record included the legal document dated March 29, 2023, noting the resident as an incapacitated adult and appointed a guardian.
Staff #1 acknowledged the resident’s legal representative did not sign the resident’s ISPs.

Plan of correction

To address the deficiency identified regarding the Individualized Service Plan (ISP) signatures, the facility will immediately implement corrective actions. We will review all current ISP documents to identify any instances where signatures from the resident's legal representative are missing. For those identified, we will promptly contact the legal representatives to obtain their signatures and ensure compliance with regulatory requirements. Moving forward, our procedures will be updated to include a systematic check during ISP creation and review processes to ensure that all necessary signatures--- by the licensee, administrator, or designee, as well as by the resident or legal representative--are obtained and dated appropriately. Staff members involved in ISP development and management will receive additional training to reinforce the importance of obtaining and documenting these signatures accurately. Regular audits will be conducted to monitor adherence to the updated procedures and ensure ongoing compliance.

22VAC40-73-450-F

Based on record reviewed and staff interviewed, the facility failed to ensure that the resident’s individualized service plan (ISP) included all assessed needs for a resident.

Evidence

On 6-28-24, resident #1’s physical examination dated 5-18-23 noted the resident has a pacemaker. This assessed need was not on the resident’s ISP dated 7-8-23. The resident’s uniformed assessment instrument (UAI) dated 7-18-23 noted the resident’s behavior as appropriate. The resident’s ISP dated 7-8-23 noted behavioral pattern need noted, ?when resident become agitated, care staff will attempt to redirect or re-approach at another time. Activities of interest will be held to limit resident’s agitation. Medication will be provided when necessary to calm resident down?.
Resident #2’s physician’s orders dated 5-1-24 and June 2024 medication administration record (MAR) noted the resident is allergic to Penicillin. The resident’s ISP dated 11-3-23 noted the resident has no allergy.
Staff #1 and #2 acknowledged the resident’s ISP did not include resident’s assessed need.

Plan of correction

To address the issues with residents' Individualized Service Plans (ISPs), we will take immediate action. We will review all current ISPs to find where medical conditions, allergies, and behavioral assessments are missing. After this review, we will update each resident's ISP to include all documented needs from their medical records, physician orders, and assessments. Staff involved in ISP development will receive training focused on accurately documenting and integrating medical information, allergies, and behavioral assessments into ISPs. We will establish a system to regularly check ISPs for accuracy and ensure they align with residents' records and assessments. Improved communication will help ensure timely updates and collaboration among healthcare providers, staff, and residents' legal representative. We will also conduct regular reviews and evaluations to make sure out ISP procedures are effective. Feedback from staff and residents' families will help us make improvements and provide better care for residents.

22VAC40-73-680-I

Based on document reviewed and staff interviewed, the facility failed to ensure medication administration record included all requirements.

Evidence

1 On 6-28-24 resident #1’s June 2024 medication administration record (MAR) was observed with missing staff initials
On 6 28 24, resident #1’s June 2024 medication administration record (MAR) was observed with missing staff initials on 6-2-24; 6-8-24 and 6-15-24 for 8:00 p.m. for medications Abilify, Voltaren arthritis, Tramadol and Ensure; Synthroid on 6-8-24 and 6-12-24 (6:00 a.m.).
Resident #2’s June 2024 MAR missing staff initials on 6-2-24; 6-8-24 ad 6-15-24 for 8:00 p.m. medications Clonidine and Zyprexa; Ensure on 6-8-24 (8:00 p.m.).
Staff #1 and #2 acknowledged the residents? June 2024 MARs did not have the initial of staff on the dates noted as required.

Plan of correction

To address these deficiencies, immediate corrective actions will be implemented. Firstly, a comprehensive review of all current MARs will be conducted to identify instances where staff initials are missing. Subsequently, staff will be reminded of the importance of initialing each medication administration promptly and accurately at the required times. Staff will receive ongoing feedback and support to ensure consistent compliance with these procedures. Enhanced communication channels will also be utilized to reinforce expectations and facilitate timely updates to MARs as necessary.

22VAC40-73-870-E

Based on observation and staff interviewed, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition.

Evidence

On 6-28-24, during a tour of the facility with staff #2 and #3 the kitchen sink in a resident’s room (#27) was observed to have standing brown colored water and it also had an odor.
Staff #2 and #3 acknowledged the kitchen sink was not in good repair and condition.

Plan of correction

To address this issue, immediate corrective actions will be implemented. Firstly, the kitchen sink in Resident Room #27 will be inspected and repaired promptly to ensure it is in good working condition. Additionally, a thorough inspection of all furnishings, fixtures, and equipment throughout the facility will be conducted to identify any other items needing repair or maintenance. Staff will receive training on the importance of promptly reporting and addressing maintenance issues to ensure all areas of the facility are kept clean, functional, and safe for residents. Regular monitoring and audits will be established to verify compliance with maintenance standards and prevent recurring similar issues.

22VAC40-73-970-E

Based on documents reviewed and staff interviewed, the facility failed to ensure fire drills were conducted for each shift in a quarter and shall not be conducted in the same month.

Evidence

On 6-28-24, the fire drill documents noted fire drills conducted 1-22-24 (6 a.m.), 2-23-24 (3 p.m.), 4-17-24 (8 p.m.) and 6- 12-24 (3 p.m.).
Staff #1 acknowledged the fire drills were not conducted as required.

Plan of correction

The fire drills mentioned in the documents were not conducted by the Fire Marshal as initially thought by Staff #1. Instead, these drills were organized and overseen by the facility's administration. The drills were announced using the fire alarm system as the form of notification to stimulate real-life emergency conditions. Staff #1's initial understanding about the Fire Marshal conducting the drills was incorrect. It appears there was confusion or misunderstanding regarding the nature of the drills and their scheduling. The drills were indeed conducted as part of our internal safety protocols to ensure staff readiness and resident safety in the event of a fire emergency. Moving forward, we will ensure clearer communication and understanding among staff regarding the origin and purpose of fire drills conducted by the facility versus those conducted by external authorities like the Fire Marshal. This will include providing additional training and clarification on the roles and responsibilities during fire drills to enhance to overall preparedness and compliance with regulatory requirements.

June 5, 2024Inspection5 violations

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments

Type of inspection: Monitoring An unannounced monitoring training was conducted on 6-5-24 with two inspectors from the Peninsula Licensing Office. (Ar 08:20 a.m./Dep 14:00). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-250-D

Evidence

On 6-5-24, staff #4’s TB document in the record was dated 5-1-24. The staff’s date of hire was noted as 4-1-24.
Staff #1 and #3 acknowledged the staffs? TB was not completed on/or prior to the date of hire.

Plan of correction

Not published by VDSS.

22VAC40-73-290-A

Based on document reviewed and staff interviewed, the facility failed to ensure the written work schedule was current.

Evidence

On 6-5-24, the housekeeping and maintenance scheduled posted in the staff break room was dated March 4 to May 4,
Staff # 2 acknowledged the aforementioned staff scheduled posted was not current.

Plan of correction

Not published by VDSS.

22VAC40-73-310-H

Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions or care needs for two of three records reviewed.

Evidence

Resident #1’s June 2024 medication administration record (MAR) and physician’s orders dated 5-1-24 noted resident prescribed Olanzapine (6-16-18) and Valproic Acid (6-10-23). The record did not have documentation for the prescribed psychotropic medications being administered.
Resident #2’s June 2024 MAR and physician’s orders dated 5-1-24 noted resident prescribed (Sertraline10-17-23) and Lorazepam (6-3-24). The record did not have documentation for the prescribed psychotropic medication.
Staff #1 and # 2 acknowledged during exit meeting the resident’s record did not contain a treatment plan for the prescribed psychotropic medication.

Plan of correction

Not published by VDSS.

22VAC40-73-450-F

Based on records reviewed and staff interviewed, the facility failed to ensure the resident’s individualized service plan (ISP) addressed all assessed needs.

Evidence

On 6-5-24, resident #1’s uniformed assessment instrument (UAI) dated 5-1-24, noted resident’s behavior is appropriate. The ISP dated 5-1-24 noted resident staff is to provide intervention when resident becomes agitated. The resident was observed being given Lamisil fungal cream during the medication pass to self-administer. The UAI noted resident’s medication is to be administered by staff. The record did not have an order resident to self-administer this medication.
Resident #3’s UAI dated 5-1-24 noted resident behavior assessed as appropriate. The ISP dated 5-6-24 noted resident is to be redirected and provided activity when resident becomes agitated.
Staff #1 and #2 acknowledged the residents UAI did not include the assessed needs noted on the ISPs.

Plan of correction

Not published by VDSS.

22VAC40-73-680-I

Based on document reviewed and staff interviewed, the facility failed to ensure medication administration record included all requirements.

Evidence

On 6-5-24, resident #1’s June 2024 medication administration record (MAR) was observed with missing staff initials on 6-2-24 for Valproic Acid (8:00 p.m.); Ensure (8:00 p.m.) and Mirtazapine (8:00 p.m.).
Resident #3’s June 2024 MAR missing staff initials on 6-2-24 for Phenobarbital (8:00 p.m.) and Refresh tears (8:00 p.m.).
Staff #1 and #2 acknowledged the residents? MARs did not have the initial of staff on the dates.

Plan of correction

Not published by VDSS.

May 9, 2024Inspection3 violations

Areas reviewed

Comments

Type of inspection: Monitoring An on-site NOI monitoring inspection conducted with two licensing inspectors from the Peninsula Licensing Office. Ar (1:45/dep 4:50 p.m.). The census was 31. The administrator was not present. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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. 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 (Willie Barnes), Licensing Inspector at (757)-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-310-H

Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions or care needs for one of six residents.

Evidence

Resident #1’s Hospice treatment plan and physician’s order dated 3-8-24 documented resident prescribed Haloperidol. Resident’s discharge medication list dated 3-6-24 noted Quetiapine psychotropic medications. The resident? s record did not have documentation of a psychotropic treatment plan.
Staff #2 acknowledged during exit meeting the resident’s record did not contain a treatment plan for prescribed psychotropic medication.

Plan of correction

A treatment plan has been developed for all the listed psychotropic drugs prescribed by the hospice physician. The administration has created a binder that includes the updated plan and arranged it alphabetically to facilitate easy review of additional documents. Date Corrected: June 15, 2024

22VAC40-73-610-B

Based on observation and staff interviewed, the facility failed to ensure that the menu for meals and snack for the current week shall be dated and posted in an area conspicuous to residents.

Evidence

On 5-9-24, at 12:29 p.m., two inspectors from the Peninsula Licensing Office, observed the facility menu posted was dated May 2 to May 8, 2024.
Staff #2 stated not having a key to open the display where the menu and activity calendar is posted.
Staff #2 acknowledged the current menu was not posted.

Plan of correction

The assigned person (activity coordinator) will be responsible for holding the key to the bulletin board. If she is on vacation, she will give it to the dietary coordinator to post the menu for the week. Date Corrected: May 10, 2024

22VAC40-73-870-E

Evidence

On 5-9-24 during a tour of the facility with staff #3, the bathtub in room #12 was missing tiles on the right side, the lower portion (step entrance) to the tub. The tub was also observed to covered in a greyish colored substance.
Staff #3 acknowledged, the bathtub and tile in room #12 was in need of repair and was not cleaned.

Plan of correction

Maintenance is currently working on all upgrades and ensuring that every room is inspected. Housekeeping is responsible for reporting any issues observed during their cleaning to management to avoid any delays in construction and repairs. The tub will be reconstructed, and efforts will be made to ensure it remains neat and clean at all times for the residents. Date Corrected: June 20, 2024

May 9, 2024Complaint survey3 violations

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint An on-site complaint inspection conducted by two inspectors from the Peninsula Licensing Office on 5-9-24 (Ar 12:27 p.m./dep 13:45 p.m.). The administrator was not present. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 4-29-24 regarding allegations in the areas of resident supervision. 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: Number of interviews conducted with residents: Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-70-A

Based on interview, the facility failed to ensure it reported to the licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health or safety, or welfare of any resident.

Evidence

On 5-9-24, during a complaint inspection, staff #2 stated the facility was required to report all incidents to the licensing office. A copy of the facility’s incident reporting policy was reviewed.
Staff did not report the police coming to the facility on 4-28-24 regarding resident #1 wandering to a residence in the neighborhood nearby. Staff #1 speaking with the police but did not contact the licensing office to report this incident.
Staff #1 acknowledged the facility did not notify the licensing office of an incident involving resident #1 on April 28, 2024.

Plan of correction

The incident reporting policy has been reviewed with all staff members, who have read and acknowledged it to reiterate the importance of reporting incidents to the administration. It is mandatory for incidents to be charted in the computer charting system, which prompts an email notification to the administration. Date Corrected: May 15, 2024

22VAC40-73-310-H

Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions or care needs for a resident.

Evidence

On 5-9-24, resident #1’s record did not have documentation of a psychotropic treatment plan for medications prescribed 4-26-24, Quetiapine Fumarate, Benztropine, Divalproex and Inderal.
Staff #2 and #3 acknowledged during exit meeting the resident’s record did not contain a treatment plan for prescribed psychotropic medication.

Plan of correction

22VAC40-73-460-D

Based on record reviewed and staff interviewed, the facility failed to ensure provide supervision to a resident’s schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.

Evidence

On 4-28-24, resident #1 wandered to a nearby home. The facility staff # 4 received a call informing that resident was on the caller’s property. Staff went and assisted resident #1 back to the facility. The police later came to the facility and spoke with staff #4 who contacted staff #1. Resident #1’s record noted resident’s absence from the facility and return by staff #4.
Resident #1’s uniform assessment instrument (UAI) dated 11-7-23 noted the resident had no behavioral needs. The individualized service plan (ISP) dated 9-8-23 noted resident’s ?occasional wandering outside the facility, walking in the parking lot to exercise?. The resident’s record noted other incidents of wandering into the community, 10-7-23. Facility was notified by the local community behavioral agency of resident being in community. On 11-14-23 resident was observed by staff #2 walking down the road in the community.
Staff #2 stated the resident was to be monitored by staff, check for meals and hourly checks. This information was not documented on the resident’s ISP.
Interviews with other staff members, staff not aware of resident’s ISP and wandering or frequent checks on resident.

Plan of correction

An updated treatment plan and instructions on how to handle instances when a resident acts up have been added to the Individualized Service Plan (ISP). Medications have been revisited to align with resident's mental and behavioral conditions. Additionally, the ISP has been posted in the computer charting record for the staff to review. Date Corrected: May 10, 2024

April 30, 2024Inspection2 violations

Areas reviewed

Comments

Type of inspection: Monitoring An unannounced monitoring inspection was conducted on 4-30-24, two inspectors from the Peninsula Licensing Office. (Ar 07:53/dep 11:57). The facility census was 31. The administrator was not present. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-320-A

Based on record reviewed and staff interviewed, the facility failed to ensure the results of a risk assessment documenting

Evidence

On 4-30-24, resident #2’s record included two tuberculosis assessments documents. The assessment did not include the date of the assessment. The resident’s date of admit to the facility was noted as 1-10-24. Staff #1 stated resident’s record included an assessment dated March 2024, that document was not in the record reviewed.
Staff #1, #2 and #3 acknowledged the resident’s record did not include a TB assessment dated on/or prior to admission.

Plan of correction

The corrective action plan regarding the TB assessment form from admission involves addressing a procedural gap identified in our documentation process. It has been observed that the TB assessment, typically included in the Hospital & Provider (H&P) documentation from the hospital, lacks a date indicating when the evaluation was completed. To remedy this oversight, Colonial Manor will initiate the necessary steps to obtain a copy of the TB assessment from the hospice company responsible for the admission. Specifically, we will request the assessment to be conducted on the same date that the resident was admitted to Colonial Manor. Date Corrected: May 15, 2024

22VAC40-73-450-C

Based on record reviewed and staff interviewed, the facility failed to ensure that the resident’s individualized service plan (ISP) included all assessed needs for a resident.

Evidence

On 4-30-24, resident #1’s uniformed assessment instrument (UAI) dated 6-8-23 noted resident was independent for all activities of daily living and ambulation. The ISP received from staff #1, noted on page 1, bathing, mechanical help (mh)- grab bars. Page 2 noted transferring, mh-use or arms of chair and grab bars to transfer and toileting, mh-use of grab bars and a cane to maintain balance while transferring on/off the toilet. Page 3, ambulation: walking, mh- uses a can and hold on grab bars to go around the facility- staff will supervise resident while walking for safety and aid when needed. Stairclimbing, human help & supervision (hh/s)- need help when climbing stairs. Mobility, mh- use can and grab bares when going outside of room. Page 6, orientation, disoriented into some spheres- difficulty with dates and times- did not include what staff should do to assist with dates and times.
Resident #2’s record noted resident receives hospice services. According to staff #2 and #3, the resident’s social worker comes and visit. The resident is also receiving nursing services.The nursing and social worker service were not documented on the resident’s ISP dated 2-9-24. The record noted a signed order dated 1-12-24 with a prescribed diabetic/cardiac diet. The ISP noted a cardiac diet. Staff #1 acknowledged these types of special diet are not specifically prepared at the facility.
Staff #1, # #2 and #3 acknowledged the residents ISP provided to the inspector on 4-30-24 did not include all assessed needs.

Plan of correction

The staff has been informed that the most recent Individualized Service Plan (ISP) and Uniform Assessment Instrument (UAI) are both accessible in the 3C's book. Additionally, the administration will take steps to update the ISP to reflect services included in hospice care and disciplines visiting the residents, such as social workers, chaplains, and nurses. This initiative ensures that our documentation accurately reflects the comprehensive care provided to our residents, including any specialized services and interdisciplinary support. Date Corrected: May 1, 2024

March 21, 2024Inspection5 violations

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

Comments

Type of inspection: Monitoring An unannounced on-site monitoring inspection was conducted on 3-21-24. (AR: 8:00 a.m. Dep: 12:20 p.m.), The facility census was 29. The administrator was not present. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-310-H

Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit nor retain individuals with prohibited conditions or care needs.

Evidence

On 3-21-24, resident #1’s was administered Bupropion (Wellbutrin) during the medication pass observation with staff #
The resident’s March 2023 medication administration record noted the resident prescribed Bupropion daily for mood. The medication label also noted the resident’s Bupropion HCL XL 300 mg tablet. The record did not have documentation of a psychotropic treatment plan for Bupropion.
Staff #1 and #2 acknowledged the resident’s record did not include a psychotropic treatment plan for the Bupropion prescribed.

Plan of correction

The action plan entails initiating persistent communication with the outside doctor to obtain their signature for Wellbutrin on the treatment plan. A clear documentation protocol will be established, and staff, particularly Registered Medication Aides, will be trained to attach necessary forms when sending medication orders. Regular reviews of treatment plans will ensure accuracy, while continuous monitoring and feedback will guide adjustments. Thorough documentation will be maintained to track progress and address any recurring issues, ensuring comprehensive care for residents at Colonial Manor. Date Corrected: March 26, 2024

22VAC40-73-325-B

Based on record reviewed and staff interviewed, the facility failed to ensure the fall risk rating was reviewed and updated at least annually for a resident.

Evidence

On 3-21-24, resident #3’s fall risk in the record was dated 2-1-22. The facility’s “Fall Risk Scale Assessment” document noted a score of 35, with instructions to initiate a care plan. The assessment form also documented it was revised by staff #7 on 10-20-22, however, the document did not include fall scores and or areas reviewed.
Staff #1 and #2 acknowledged the resident’s record did not include a current/ annual fall risk rating.

Plan of correction

The action plan involves educating staff on the importance of conducting fall assessments annually and with each new resident's fall incident. This includes ensuring the new form is included in each assessment and that points are totaled accurately. Additionally, there will be a monthly review of the fall assessment for each resident to monitor any changes or trends. This comprehensive approach aims to enhance resident safety and minimize fall risks at all times. Date Corrected: March 21, 2024

22VAC40-73-440-H

Based on record reviewed and staff interviewed, the facility failed to ensure an annual reassessment, using the uniform assessment instrument (UAI), was utilized to determine whether a resident’s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.

Evidence

On 3-21-24, resident 1’s record did not have documentation of a reassessment using the public pay UAI. The public pay UAI in the record was dated 3-2-22. The documented noted it was revised by staff #7 on 11-9-22. Staff #7 not qualified to complete public pay UAI.
Staff #1 acknowledged the resident’s record did not have documentation of a reassessment using the UAI since 3-2- 22.

Plan of correction

Following multiple unsuccessful attempts to obtain the UAI for Colonial Manor through email and phone calls to the support coordinator, an immediate resolution was achieved by directly contacting the office and requesting to speak with the supervisor, resulting in the prompt delivery of the UAI to my attention and its posting in the Resident chart. Communication to the Support Coordinator will continue to achieve a prompt response before it expires. Date Corrected: March 25, 2024

22VAC40-73-450-F

Based on record reviewed and staff interviewed, the facility failed to ensure that the resident’s individualized service plan (ISP) included all assessed needs for a resident.

Evidence

On 3-21-24, resident #3’s physician’s order sheet (POS) dated 1-2-24, noted resident’s allergy to Prozac. The resident? s ISP dated 5-8-23 noted the resident had “no known allergy”.
Staff #1 and #2 acknowledged the resident’s ISP did not include resident’s assessed need.

Plan of correction

The Corrective Action Plan (CAP) for the missed inclusion of allergy information in Resident #3's Individualized Service Plan (ISP) entails implementing diligent monitoring by the administration office throughout the ISP writing and review process to prevent the recurrence of such oversights. This correction was immediately done after the licensing inspector left. Date Corrected: March 21, 2024

22VAC40-73-610-C

Based on observation, document reviewed, staff and resident interviews, the facility failed to ensure the items noted on the posted menu were served and or substitutions noted and meet the U.S. Department of Agriculture’s food guidance system or dietary allowances of the Food and Nutritional Board of the National Academy of Sciences, taking into consideration of the age, sex, and activity of the residents. ,

Evidence

On 3-21-24, the LI observed the breakfast meal being served. The fruit served was clementine. The residents? plates were observed to contain half of a small clementine. Staff #5 was asked to show the inspector the fruit being served with breakfast. A bag of small clementines was observed being used for the breakfast meal. The clementine was being cut in half and each resident was served half of the small clementine.
Staff #5 acknowledged the residents were not provided a serving of fruit during the breakfast meal.

Plan of correction

The action plan consists of educating the entire dietary crew on the importance of knowing the appropriate serving amounts of food for each resident. This education will emphasize adherence to the guidelines outlined in the Dietary book in the kitchen and the menu. By ensuring that all staff members understand these standards, we aim to maintain consistency in serving sizes and provide residents with the appropriate nutrition they require. Date Corrected: March 22, 2024

February 22, 2024Inspection3 violations

Inspection dates

Feb. 22, 2024

Areas reviewed

Comments

Type of inspection: Monitoring An unannounced monitoring inspection was conducted on 2-22-24 with two inspectors from the Peninsula Licensing Office. The facility census was 31. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-325-B

Based on record reviewed and staff interviewed, the facility failed to ensure the fall risk rating was reviewed and updated at least annually for a resident.

Evidence

On 2-22-24, resident #3’s fall risk in the record was dated 12-13-22; resident’s date of admit noted as 2-22-18. The resident uses mechanical device to move around the facility.
Staff #2 and #3 acknowledged the resident’s record did not include a current/ annual fall risk rating.

Plan of correction

Review the fall assessment for Resident #3, ensure staff are trained properly, monitor quality closely, establish clear documentation guidelines, improve communication, foster continuous improvement, enforce accountability, and conduct follow-up reviews. Date of Correction: February 22, 2024

22VAC40-73-450-F

Based on record reviewed and staff interviewed, the facility failed to ensure that the resident’s individualized service plan (ISP) included all assessed needs for a resident.

Evidence

On 2-22-24, resident #3’s uniformed assessment instrument (UAI) dated 6-29-23 noted resident incontinent of bladder. The ISP dated 6-29-23 documented, resident’s bowel incontinence. Wheeling need assessed as not performed. The ISP noted resident does not need help; use of wheelchair, resident propels self independently in wheelchair. Stairclimbing accessed as mechanical help. The ISP noted stairclimbing not performed, the facility is a one level building.
Staff #2 and #3 acknowledged the resident’s ISP and assessed needs did not agree.

Plan of correction

Resident #3 is a public UAI, and their case worker conducted the UAI, noting that the resident is continent on both bladder and bowel; therefore, a note will be added to the ISP indicating occasional bowel incontinence to align with the ISP created by the case worker. Date of Correction: February 22, 2024

22VAC40-73-550-G

Based on records reviewed and staff interviewed, the facility failed to ensure that the residents? rights and responsibilities were completed annually.

Evidence

On 2-22-24, the facility did not have signed and dated documentation of the annual review of resident’s rights and responsibilities for resident #1. The resident’s date of admit was dated 11-19-21.
Staff #2 and #3 acknowledged the resident’s record did not include documentation of resident’s rights and responsibilities.

Plan of correction

Review the R & R for Resident #1 Administration will establish clear documentation guidelines, improve communication, foster continuous improvement, enforce accountability, and conduct follow-up reviews. Date of Correction: February 22, 2024

January 22, 2024Inspection11 violations

Inspection dates

Jan. 22, 2024 and Feb. 28, 2024

Areas reviewed

Comments

Type of inspection: Monitoring An unannounced monitoring inspection was conducted. The focus of the inspection was to determine whether the provider had corrected or is in the process of correcting previously cited violations in the areas of standards referenced above. Any non-compliant elements of law or regulations are documented in the Violation Notice of this inspection. This inspection found the provider to demonstrate noncompliance with standards not identified in the plan of correction. An unannounced monitoring inspection was conducted on 1-22-24 with two inspectors from the Peninsula Licensing Office. The facility census was 31. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-250-C

Based on record reviewed and staff interviewed, the facility failed to ensure that a staff personal and social data included all required information.

Evidence

On 1-22-24, staff #4’s record did not include verification of having received a copy of the staff’s current job description. Staff’s date of hire noted as 12-19-23 as a personal care aide/direct care staff.
Staff #2 acknowledged the staff’s record did not include a signed job description.

Plan of correction

After the inspection, the job description was promptly filed in the staff #4 folder and duly signed by staff #4. The Assistant Administrator has developed a checklist outlining the essential documents required in each file, ensuring their inclusion in subsequent hiring processes. Date to be corrected: January 25, 2024

22VAC40-73-260-C

Based on document reviewed and staff interviewed, the facility failed to ensure the posted listing of staff person with certification in first aid or cardiopulmonary resuscitation (CPR) was kept up to date.

Evidence

On 1-22-24, the first aid/ CPR posting in the nursing station reviewed with staff #3 did not include staff #4, date of hire 12-19-23.
Staff #3 acknowledged that staff’s name was not included on the posted first aid/CPR listing.

Plan of correction

Staff number 4's CPR record was promptly integrated into the current CPR lists displayed at the nurse station. The administration will annotate the date of the file update to ensure that all new hires are included in the latest posted list. Date to be corrected: January 22, 2024

22VAC40-73-310-H

Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit nor retain individuals with prohibited conditions or care needs.

Evidence

On 1-22-24, resident #4’s record documented resident prescribed Lorazepam psychotropic medications, (admission physical and POS). The record did not include a psychotropic treatment plan.
Staff acknowledged the aforementioned resident’s record did not include a psychotropic treatment plan for the Lorazepam.

Plan of correction

All psychotropic medications will be accompanied by a treatment plan. A meeting was held with all Registered Medication Aides (RMAs) to ensure that physicians sign off on these treatment plans as mandated by state regulations. Additionally, it's noted that Resident #4's treatment plan has been submitted to the Hospice Company to obtain the signature from the Hospice doctor. The Assisted Living Facility is committed to complying with all relevant regulations. Date to be corrected: January 22, 2024, February 5, 2024

22VAC40-73-325-B

Based on record reviewed and staff interviewed, the facility failed to ensure the fall risk rating was reviewed and updated at least annually for a resident.

Evidence

On 01-22-24, resident #1’s fall risk in the record was dated 12-2-22; resident’s date of admit noted as 12-1-19. The resident is assessed as physically non-ambulatory and uses a geri-chair for mobility.
Resident #3’s fall risk in the record was dated 5-1-21 and revision dated noted 12-2-22; resident’s date of admit noted as 7-24-19. The resident is assessed as physically non-ambulatory and uses a high-back wheelchair for mobility.
Staff #1 and #3 acknowledged the aforementioned residents? record did not include a current/ annual fall risk rating.

Plan of correction

Not published by VDSS.

22VAC40-73-450-A

Based on record reviewed and staff interviewed, the facility failed to ensure a plan of care was developed to address the basic needs of the resident on or with in seven days prior to the day of admission.

Evidence

On 1-22-24, resident #4’s care plan in the record need date was noted as 1-12-24. The date of the care plan developed by staff #3 and #4 was as 1-11-24. The resident’s date of admit was noted as 1-10-24. Staff #2 verified resident #4’s date of admit as 1-10-24.
Staff acknowledged the aforementioned resident’s care plan was not developed on or prior to admission.

Plan of correction

All psychotropic medications will be accompanied by a treatment plan. A meeting was held with all Registered Medication Aides (RMAs) to ensure that physicians sign off on these treatment plans as mandated by state regulations. Additi it' t #4' t itt d t Additionally, it's noted that Resident #4's treatment plan has been submitted to the Hospice Company to obtain the signature from the Hospice doctor. The Assisted Living Facility is committed to complying with all relevant regulations. Date to be corrected: January 22, 2024, February 5, 2024

22VAC40-73-450-F

Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s updated individualized service plan (ISP) included all assessed needs.

Evidence

On 1-22-24, resident #1’s physician’s orders dated 09-27-23 and 6-8-23 noted resident prescribed a puree diet. The ISP dated 10-2-23 documented resident receives a mechanical soft diet. The resident was observed being spoon-fed a mechanical soft diet by staff #5 during the breakfast and lunch meals. The approximate time needed for meals to ensure needs was met was not documented on the resident’s ISP. The resident was observed eating and being pushed by staff in a geri-chair, this item was not documented on the resident’s ISP. The resident assessed as disoriented some spheres all the time. The ISP noted resident to be redirected but did not state how or when staff should redirect. The resident was also assessed as verbally aggressive, but staff stated resident did not talk.
Resident #2’s UAI dated 6-1-23 noted bathing need assessed as mechanical help/physical assistance/human help. The ISP dated 6-12-23 noted “staff will supervise resident into the shower chair and standby assistance for safety”. Dressing need assessed as mechanical help/physical assistance/human help. The ISP noted, ?human help with physical assistance; resident will receive help from Direct Care Aide?. The care plan did not document what mechanical device was needed to provide care. Walking need assessed as yes but no category is assessed. The ISP noted ?walking with mechanical help with supervision?. Resident observed walking to around the facility, up and down the hallway without staff supervision. The fall risk information on ISP noted “resident cannot walk independently without any assistance.” Resident observed using a sippy cup during breakfast and lunch meal. The record did not have documentation or a physician’s order for a special cup for drinking. Staff #1 stated staff provides cup to keep resident from spilling liquid on clothing. The resident’s physician’s order dated 10-11-23 noted “no concentrated sweets (NCS) diet”, the ISP noted regular diet.
Staff #2 acknowledged the aforementioned residents? UAI, record documents and ISP did not include all assessed needs.

Plan of correction

1. All new physician orders, including diet orders, must be carefully reviewed. In response to this requirement, the office has requested physicians to sign a new set of diet order forms to ensure thorough documentation and compliance with regulations. This measure aims to enhance the accuracy and completeness of resident care plans. 2. The Individual Support Plan (ISP) and Uniform Assessment Instrument (UAI) must align, but concerns have arisen regarding discrepancies between the Private and Public UAI. Due to the unavailability of the case worker to correct or update the UAI, the ISP will include annotations explaining any changes. This ensures that reviewers or inspectors understand the reasons for any discrepancies between UAI and ISP for Public UAI residents. Date to be corrected: January 23, 2024

22VAC40-73-550-G

Based on records reviewed and staff interviewed, the facility failed to ensure that the residents? rights and responsibilities were completed annually.

Evidence

On 1-22-24, the facility did not have signed and dated documentation of resident #1, #2 and #3’s annual resident rights and responsibilities. Staff #3 stated the resident rights were conducted 10-6-23.
During the exit meeting on 1-22-24, staff #2, dated resident #3’s annual rights as “10-6-23 and Jan 22/2024 AOH”.
Staff acknowledged the resident’s rights were not signed and dated.

Plan of correction

Colonial Manor conducts an annual Rights & Responsibility Acknowledgement with all residents. To maintain thorough documentation, Colonial Manor will ensure that each signed document is dated and filed in the chart of each resident. This process guarantees compliance with regulatory requirements and facilitates efficient record-keeping for resident care. Date to be corrected: January 22, 2024

22VAC40-73-610-B

Based on observations and staff interviewed, the facility failed to ensure menu substitutions or additions was recorded on the posted menu.

Evidence

On 1-22-24, the posted breakfast menu for the day noted waffle with cheese sandwich, scrambled eggs, grits, cold cereal, and fruit (sliced apple). Pancakes with syrup was observed served during the breakfast meal. The menu did not note a change or substitution for the pancakes observed.
Staff acknowledged the menu was not updated to note the change or substituted item.

Plan of correction

Any changes to the posted menu will be promptly corrected. A meeting was held with the Dietary crew to underscore the importance of this rule. Additionally, it was emphasized to each member of the dietary staff that any changes must be reported to management for authorization, as all posted menus are verified to ensure availability. This ensures consistency and accuracy in meal offerings for our residents. January 22, 2024, February 5, 2024

22VAC40-73-640-A

Based on record reviewed, observation and staff interviewed, the facility failed to ensure it followed its medication management policy.

Evidence

On 1-22-24, following the medication pass observation with staff #3 and a check of PRN (as needed) medication, resident #3’s Nitroglycerin for chest pain had an expiration date of 3-24-23.
Staff # 3 acknowledged the resident’s PRN medication was outdated and not available.

Plan of correction

Colonial Manor will liaise with the Pharmacy to confirm whether the previously conducted cart audit included the removal of expired medication. The administration will compile a list of all medications pulled during each cart audit. Furthermore, a meeting with Registered Medication Aides (RMAs) was held to reinforce the importance of conducting thorough weekly inspections for expired medications, which will then be promptly removed and sent to the Pharmacy for proper disposal. Efforts will also be made to procure replacements for any expired medication. This proactive approach ensures the safety and well-being of our residents by maintaining the integrity of their medication supply. Date to be corrected: January 22, 2024, February 5, 2024

22VAC40-73-870-A

Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair.

Evidence

On 1-22-24 during a tour of the facility, the ceiling in the new dining room on the assisted living level hallway was observed to have a stain area in the ceiling that was approximately 12 by 8 inches.
Staff #2 acknowledged the ceiling was stained.

Plan of correction

A new dining room ceiling was stained, and a maintenance order was promptly dispatched to rectify the issue. The ceiling was repainted with the closest color available to restore its appearance. This swift action ensures the upkeep and aesthetic appeal of the dining area for the comfort and satisfaction of our residents. Date to be corrected: January 25, 2024

22VAC40-73-980-H

Based on observations and staff interviewed, the facility failed to ensure the availability of the 96-hours supply of emergency food which include the facility’s rotating stock used was kept current.

Evidence

On 1-22-24 the facility’s current rotating food stock, the following items were noted with expired dates: (a) Tortilla chips, 5 boxes of 36 (1.5 oz bags) noted an expiration date 13-Oct 2023, (b) Mac and Cheese, 9 boxes ( 7.25 oz) noted a best by date 10-Dec 2022; (c) Mayonnaise, 2 (1 gal) jars, noted a best by date 01-08-2024; (d) French Style green beans, 1 can (12.oz), expired 12-28-2023 and (e) Parboiled yellow rice, 1 bag (10 oz)2, best by Sep 20, 2023; (f)
Staff #1 and #2 acknowledged the facility’s food supply contained foods with expired dates/best by dates.

Plan of correction

All expired food items have been promptly removed from the pantry. A meeting was conducted with the kitchen crew on February 5 to emphasize the importance of verifying expiration dates on all supplies and ensuring proper rotation with every new delivery. This proactive approach guarantees the freshness and quality of our food supplies, upholding our commitment to providing safe and nutritious meals for our residents. Date to be corrected: January 22, 2024, February 5, 2024

December 16, 2023Complaint survey6 violations

Inspection dates

Dec. 16, 2023 and May 31, 2023

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint An unannounced complaint inspection conducted by two inspectors (LI/LA) on 12-16-2022. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11-29-2022 and 10-11-2022 regarding allegations in the staffing and resident care and related services (food- staffing- and the building) Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 6 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-150-F

Based on interview, the facility licensed for both residential and assisted living care, the administrator shall serve on a full- time basis as the on-site agent of the licensee and shall be responsible for the day-to day- administration and management of the facility.

Evidence

On 12-16-22, during a complaint inspection regarding the administrator not being at the facility, the administrator did not have a schedule of days and/or times at the facility. The administrator acknowledged not being in the country the first week in November 2022. When asked what days the resident was out of the country, the administrator proceeded to look for the days in his phone but did not provide the inspectors with days or times the administrator was not in the United States of America.
Staff #2 stated not being in the country November 5, 2022 to November 28, 2022.
The administrator’s schedules dated 8-14-22 to 9-25-22 and 9-26-22 to 11-6-22, documented the administrator’s hours. The administrator schedule did not reflect administrator’s presence on a full-time basis as the on-site agent of the licensee. The schedule noted the following hours: 8-14 to 8-21-22 (21 hours (h); 8-22 to 8-28 (30-h); 8-29 to 9-4-22 (16.5 h); 9-5 to 9-11-22 (25 h); 9-12 to 9-18-22 (35 h); 9-19 to 9-25-22 (24 h); 9-26 to 10-2-22 (34.5 h); 10-3 to 10-9-22 (23 h); 10- 10 to 10-16-22 (23.5 h); 10-17-to 10-23-22 (31 h); 10-24 to 10-30-22 (16.5 h) and 10-31-11-6-22 (30 h).
The facility did not have documentation of who was in charge, and responsible for the day-to day administration in the administrator and assistant administrator’s absence.

Plan of correction

The provider did not provide a plan of correction.

22VAC40-73-280-A

Based on documents reviewed and staff interviewed, the facility failed to ensure it had staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental and psychosocial well-being of each resident as determined by the resident assessments and individualized service plans.

Evidence

On 12-16-22 during a complaint inspection, the direct care staff scheduled provided noted one direct care staff schedule on multiple days and shifts to provide services. The facility census was 33, and has residents assessed at the assisted living level of care requiring assistance with bathing, feeding, incontinent care and transferring. The is one staff to administer the medication for two medication carts for thirty- three residents, twenty-two residents come to the nursing station, the other staff must go to their rooms. The facility was also on fire-watch duties The facility’s vehicle has not been available to transport residents to appointments since the summer of 2022. According to staff interview, the resident’s special medical appointments were rescheduled because there was no vehicle and no transportation driver; (special medical appointments: urology, gastrointestinal, hernia surgery).
The direct care staff schedule for 8-14 to 9-24-22 (6a- 2:30 p shift) noted one staff fourteen days and 2p to 10:30p shift noted one staff 10 days. The schedule dated 9-25 to 11-5-22 (6a-2:30 p shift) noted one staff 30 days and 2- to 10:30p shift noted one staff 11 days. The schedule dated 11-6 to 12-17-22 (6a-2:30p shift) noted one staff 32 days and 2p to 10:30p shift noted one staff fourteen days.

Plan of correction

Not published by VDSS.

22VAC40-73-290-A

Based on documents provided by and staff interviewed, the facility failed to ensure the written work schedule indicated whoever is in charge at any given time.

Evidence

The facility staff schedules provided by staff #2 (administrator, housekeeping, registered medication aide, direct care staff and dietary) did not indicate who was in charge at any given time.

Plan of correction

Not published by VDSS.

22VAC40-73-610-B

Based on observation and staff and resident interviews, the facility failed to ensure the menus and snacks for the current week was dated and posted in an area conspicuous to residents.

Evidence

On 12-16-22, during the inspector and licensing administrator’s tour of the facility, the menu for the current week was not posted. Upon posting the menu did not document the substitution of sausage for ham for the breakfast meal observed.
Staff # 3 acknowledged the menu was not posted and the substitution not documented.

Plan of correction

Not published by VDSS.

22VAC40-73-870-D

Based on interview, the facility failed to the building was kept free of infestations of insects and vermin. The ground shall be kept free of their breeding places.

Evidence

On 12-16-22, interview with staff #4, regarding an allegation of scabies, the staff stated no residents had scabies. Staff #4 stated room 32 and 10 were sprayed for bed bugs. A request for the facility’s documentation of pest control report on 12-16-22 was not provided with requested documents. A second request was made on 12-22-22 without success.

Plan of correction

Not published by VDSS.

22VAC40-73-870-E

Evidence

On 12-26-22 during a tour of the facility, the female, public bathroom located across from the nursing station was not working. Staff stated the bathroom had been out of order for at least a week.

Plan of correction

Not published by VDSS.

December 11, 2023Inspection8 violations

Inspection dates

Dec. 11, 2023 and Jan. 3, 2024

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSING PROCESS

Comments

Type of inspection: Monitoring An unannounced Monitoring Inspection conducted on 12-11-23 by two inspectors from the Peninsula Licensing Office (Ar 09:10 a.m./dep 16:10 p.m. Census was 29, administrator and assistant not present, but arrived later during the inspection. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Wilie.Barnes), Licensing Inspector at (757- 439-6815) or by email at Willie. Barnes@dss.virginia.gov

Violations

22VAC40-73-80

Based on record reviewed and staffs interviewed, the facility failed to ensure that there was documentation that the resident had requested the facility to assist with the management of personal funds.

Evidence

On 12-11-23, the facility did not have documentation of the resident’s request that the facility assists with the management of personal funds for resident #1, #2, #3 and #4.
Staff #1 and #2 stated the residents have debit cards that document the resident’s personal funds and tracks the resident's spending. Staff stated keeping debit cards for residents #1, #3 and #4 in the office.
When asked to review the documentation signed and dated by the resident giving the facility permission to assist with maintain the debit card, staff #1 and #2 stated not having documentation of this request and delegation.
On 12-11-23, staff #1 and #2 acknowledged not having documentation in the residents“ record of the residents” request and delegation for the facility to assist with management of personal funds.

Plan of correction

The Colonial Manor administration office has developed a form that residents sign as part of the delegation statement process, and these signed forms will be kept in each resident's record to ensure compliance with state regulations. Date to be corrected: January 5, 2024

22VAC40-73-120-B

Based on record reviewed and staff interviewed, the facility failed to ensure the staff record included documentation of the staff oriented to the facility’s organizational structure within seven working days of employment.

Evidence

On 12-11-23, staff #5’s record did not have documentation of the organizational structure. The signature and date section of the document in the record was blank.
Staff #2 acknowledged the organizational chart was not signed and dated by the staff, acknowledging the training occurred within the first seven working days of employment.

Plan of correction

The administration office provided a new employee with a printed copy of the organizational chart to sign, and the signed copy has been posted in the employee's record. Additionally, a check-off form has been created for each employee record to ensure the completion of all necessary forms and prevent any oversights. Date to be corrected: January 5, 2024

22VAC40-73-210-E

Based on record reviewed and staff interviewed, the facility failed to ensure staff completed training relevant to the population in care and shall be provided by qualified individual through in-service training programs or institutes, workshops, classes, or conferences.

Evidence

On 12-11-23, a review of staff #1’s record did not include documentation of staff training for the population in care. The record did not include documentation of oxygen training and training for adults with mental impairments. The facility currently has residents with diagnosis of schizophrenia, bipolar and other mental impairments other than dementia.
Staff #1 acknowledged not having all required training.

Plan of correction

The administrator has enrolled in a class for additional required training, and upon completion, the certification will be promptly posted in his file. Furthermore, all training certifications are consistently displayed in the breakroom for everyone's visibility. Date to be corrected: February 15, 2024

22VAC40-73-450-F

Based on document reviewed and staff interviewed, the facility failed to ensure the resident’s individualized service plan (ISP) reflected the assessed needs.

Evidence

On 12-11-23 resident #8’s private pay uniform assessment instrument (UAI) dated 5-20-23 noted feeding/eating assessed as no help needed. The individualized service plan (ISP) dated 5-20-23 noted the resident’s meal is mechanical soft. The resident’s physician’s order dated 10-20-22 also noted a mechanical soft diet with thicken nectar liquids.
Resident #1’s public pay uniform assessment instrument (UAI) dated 10-31-23 noted feeding/eating assessed as no help needed. The resident’s physician’s order dated 11-16-22 noted a mechanical soft diet. The ISP dated 11-1-23 noted a mechanical soft diet. The UAI also noted resident’s allergy to Sulfa drugs, this was not noted on the ISP.
Staff #2 and #4 acknowledged the resident’s meal/feeding on the UAI was not accurately assessed; resident’s diet is mechanically altered- mechanical help.
Staff #2 and #4 acknowledged the residents? UAI and ISP did not agree.

Plan of correction

The private UAI will undergo a thorough review and be mirrored on the Individualized Service Plan (ISP). In the case of the public UAI, communication will be established with case workers, advising them to schedule regular meetings for review to ensure the accuracy of the UAI in reflecting everyone's daily routine and capabilities. Date to be corrected: January 5, 2024

22VAC40-73-610-C

Evidence

On 12-11-23, the lunch menu posted noted ham and cheese sandwich, French fries, chips, and fresh fruit. Interviews and observation of resident’s plate noted, grilled cheese sandwich on hot dog buns for some residents, three to four strips (approximately 1 inch) of ham were on the side of the plate. Also observed were three to four grapes and a thinly sliced orange on the plate. There were not chips observed on the residents? plates. None of the residents interviewed stated receiving chips.
On 12-11-23, the two bags of 7/8 ounce chips in the food storage area were dated 12-5-23. The inspectors did not observe any other chips in the food storage areas (the kitchen, food storage across from administrator’s office and room 22). There was no substitution for the chips noted on the posted menu.
Dietary staff interviewed, stated, the food for the menu for the day is provided by the administrative staff and whatever is provided is what is served.

Plan of correction

The facility has employed a new Coordinator exclusively dedicated to monitoring the kitchen. This Coordinator will be responsible for submitting all necessary items for ordering, and menus will be crafted based on ingredients and supply availability in the pantry. A new contract with Sysco has been initiated to ensure consistent delivery of supplies. Date to be corrected: December 15, 2023

22VAC40-73-680-M

Based on observation, document reviewed, and staff interviewed, the facility failed to ensure medications ordered for PRN administration was available, properly labeled for the specific resident and properly stored at the facility.

Evidence

On 12-11-23 during a medication observation pass with staff #4, resident #8’s Tussin (Robitussin) noted on the physician’s order dated 12-3-23 and December 2023 medication administration record (MAR) was not available on the medication cart and not in the facility.
Staff #4 acknowledged the resident’s PRN Tussin (Robitussin) was not available on the medication cart and not in the facility.

Plan of correction

A new memorandum has been established instructing the facility to fax any medication orders following each visit from the Primary Care provider. The pharmacy will then assess and determine the new and current orders for the residents, aiming to prevent any missing information after each visit. Date to be corrected: January 9, 2024

22VAC40-73-870-E

Evidence

On 12-11-23 during a tour of the facility with staff #4, the secure sealant to the pipe/tubing for the hot water heater locater in the laundry room near the nursing station was coming apart from the ceiling. The metal/stainless steel was not sealed/flushed and grounded to the ceiling. This issue was previously cited on 5-4-23.
Staff #4 acknowledged the fixture was not in good repair and condition.

Plan of correction

The facility has initiated another order to address the pipe issue on the ceiling. Additionally, the dryer, which was causing the pipe to shift due to squeezing, has been relocated away from the problematic area. Staff members have also been educated to avoid overloading machines to prevent excessive shaking, which could compromise the stability of the pipe. Date to be corrected: December 15, 2023

22VAC40-73-980-H

Based on observation, staff and collateral interviews, the facility failed to ensure the food supply was current.

Evidence

On 12-11-23 during a tour, the facility’s current rotating food stock, the following items were noted with expired dates: (a) Raspberry Walnut Vinaigrette dressing- 1 gallon container, dated 8-14-23, (b) Peanut Butter, dated 11-25-23, (c) Grated Parmesan Cheese, 2- 24 oz, dated 12-26-22 and 11-6-23; (d) Grits, 3- 80 ounce packages, dated 8-7-23 and (d) Garlic Parmesan Wing Sauce- 64-ounces, dated 9-19-23. Potato chips were noted earlier with menu.
There were also dented items on the shelf: Spaghetti Sauce, 2 (6.63 pound- #10 cans), Mandarin Orange- 1 can and a can of Cream of Mushroom soup.
Staff #1, #2, and #4 acknowledged the facility’s food supply contained dented cans items and foods with expired dates.

Plan of correction

The administration office has communicated with Sysco, notifying them that Colonial Manor will reject the delivery of any shipment with damaged or dented items. Additionally, a newly appointed Coordinator, solely dedicated to kitchen monitoring, will be responsible for identifying and removing any expired or dented items from the supply inventory. Date to be corrected: December 15, 2023

November 29, 2023Inspection5 violations

Inspection dates

Nov. 29, 2023 and Dec. 11, 2023

Areas reviewed

Comments

Type of inspection: Monitoring An on-site monitoring inspection conducted on 11-29-23 (Ar 08:45 a.m./dep 12:10 p.m.) Facility census 30. The administrator was not present. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-70-A

Based on record reviewed, document reviewed, and staff interviewed, the facility failed to ensure it reported to the regional licensing office within 24 hours any major incident that has negatively impacted affected or that threatens the life, health, safety, or welfare of any resident.

Evidence

On 11-29-23, resident #1’s record included a discharge summary from a local hospital documenting an injury to the resident’s left forearm and parotiditis.
The resident’s progress notes dated 11-2-23 at 11:20 a.m. documented the resident’s family member inquired of facility staff, ?concern about a bruise on resident left forearm the nurse practitioner contacted and stat order for an X-ray.
According to staff #1 and #3, facility did not know how injury occurred until being informed by the resident’s family member.
Staff #1 acknowledged; the facility did not know report the incident to the licensing office.

Plan of correction

1.Colonial Manor has implemented computer charting to ensure timely incident notifications to the administrator. This technological upgrade will facilitate prompt reporting and enhance our commitment to resident safety.

22VAC40-73-325-A

Based on record reviewed and staff interviewed, the facility failed to ensure a resident who met the criteria for assisted living care by the time the comprehensive individualized service plan (ISP) is completed, a written fall risk rating shall be completed.

Evidence

On 11-29-23, resident #1’s record noted a date of admission on 1-5-23, and the comprehensive service plan dated 2-5-
The record did not include documentation of a written fall risk rating.
Staff #1 and #3 acknowledged the resident’s record did not include a fall risk rating.

Plan of correction

We recognize the critical importance of such assessments in ensuring the safety and well-being of our residents. Immediate corrective measures are being implemented to address this lapse: 1. Retrospective Assessment: A comprehensive fall risk assessment will be conducted for the resident in question without delay to rectify the initial oversight. 2. Review of Admission Procedures: We are reviewing and revising our admission protocols to ensure that fall risk assessments are consistently and promptly carried out for all new residents. 3. Staff Training: All relevant staff members will undergo retraining to emphasize the importance of conducting fall risk assessments upon admission and to reinforce adherence to established protocols. 4. Process Enhancement: We are enhancing our admission documentation process to include mandatory fields for fall risk assessment.

22VAC40-73-450-C

Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s individualized service plan (ISP) included all assessed needs.

Evidence

On 11-29-23, resident #1’s uniformed assessment instrument (UAI) 2-7-23 noted bathing need as human help/physical assistance. The ISP dated 2-5-23 noted bathing as ?human help and supervision. Staff supervise resident into the shower chair and standby assistance for safety?. Toileting need assessed as human help/supervision. The ISP noted, ?mechanical & human supervision help. Resident use grab bars to maintain balance while transferring on/off the toilet?. Staff will supervise and assist per resident request and as needed“. Transferring assessed as no help needed. The ISP noted, ”mechanical & Human & Supervision assistance. Resident uses arms or chairs, and grab bars to transfer.“ Walking assessed as mechanical help. The ISP noted, ” mechanical help and supervision. Resident will use a walker for balance to reduce the risk of injury while ambulating. Staff will supervise resident safety and provide assistance as needed?. Stairclimbing assessed as human help/physical assistance. The ISP noted, ?mechanical, human help & supervision. Resident will use handrails when using stairs. Staff will supervise resident when using stairs for safety & provide assistance when needed?.
Resident’s personal and social data noted resident allergy to “wheat, iodine and gluten”. The ISP noted, ?Allergies: NKA, no known allergy?.
Staff #1 acknowledged the aforementioned resident’s assessed needs and the services on the care plan did not agree.

Plan of correction

The error has been corrected promptly. Re-training and reminder discussions have been conducted with the staff responsible for the ISP and UAI to ensure accurate and consistent documentation in the future.

22VAC40-73-680-M

Based on record reviewed, observation and staff interviewed, the facility failed to ensure medications ordered for PRN, as needed, administration was available, properly labeled for the specific resident, and properly stored at the facility.

Evidence

On 11-29-23, following medication pass observation with staff #3, a check of the resident #2’s medication determined the following PRN medications were not available: (a) Albuterol U/D 0.083% solution for shortness of breath; (b) Eucerin cream for dry skin and (c) Almacone -2 liquid (Mylanta) for indigestion.
Staff # 3 acknowledged the resident’s PRN medications were not available on 11-29-23.

Plan of correction

1. The issue has been promptly addressed by resubmitting the order to the pharmacy for replenishment. We are committed to ensuring the continuous availability of medications as required.

22VAC40-73-700-2

Based on observation and staff interviewed, the facility failed to ensure it posted “No Smoking-Oxygen in Use” sign and enforce the smoking prohibition in any room of the building where oxygen is in use.

Evidence

On 11-29-23, during a tour of the facility with staff #2 and #3, oxygen tanks and concentrator were observed in room
There was no sign posted indicating “No Smoking-Oxygen in Use”.
Staff #2 and #3 acknowledged there was no sign posted for resident #2’s room where oxygen tanks and concentrator were present.

Plan of correction

Not published by VDSS.

October 23, 2023Inspection7 violations

Inspection dates

Oct. 23, 2023 and Oct. 31, 2023

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments

Type of inspection: Monitoring A joint on-site monitoring inspection was conducted on 10-23-23, two inspectors from Peninsula licensing office. (AR 08:42 am./Dep 18:00. The facility census was 30. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The final exit meeting will be scheduled. 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 (Willie Barnes), Licensing Inspector at (757)-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-70-A

Based on record reviewed and staff interviewed, the facility failed to ensure it reported to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety or welfare of any resident.

Evidence

On 10-23-23, resident #2’s progress note dated 6-22-23 noted the resident was admitted to a local hospital for psychiatric treatment. The resident’s discharge summary document noted the resident admit days were 6-21-23 to 6-29-
Staff #1 acknowledged the resident’s psychiatric admission was not reported to the licensing office.

Plan of correction

It's commendable that Colonial Manor has taken steps to prevent incidents of failing to report important information to the licensing authorities. The facility can ensure that critical details are not overlooked by creating a new system that streamlines the process and makes it easier to input information. Additionally, the ability for management to promptly access and forward this information to the licensing authorities enhances transparency and compliance with regulations, ultimately benefiting both the facility and the residents it serves. This proactive approach to compliance is crucial for maintaining high standards of care and adherence to legal requirements. Date to be corrected: November 1, 2023

22VAC40-73-250-D

Evidence

On 10-23-23, staff #6’s record did not include a date the tuberculosis (TB) assessment was completed. The staff’s date of hire noted as 10-2-23.
Staff #9’s record did not include a date of the TB assessment was completed. The staff’s date of hire noted as 10-11-
Staff #1 and #2 acknowledged the staff’s record did not include the date the assessment was completed noting the absence of TB in a communicable form.

Plan of correction

A new Tuberculosis screening process is now a mandatory step in each hiring procedure. New employees must provide proof of their TB screening before they can commence work. Date to be started: November 1, 2023

22VAC40-73-260-C

Based on observation, staff interviewed, and document reviewed the facility failed to ensure the first aid/CPR listing indicating by staff person whether the certification is in first aide or CPR or both was kept up to date.

Evidence

On 10-23-23, the first aid and CPR posted in the medication room was not current. The names of staff members listed noted expired certificate date of 8/2023, 6/2023 and 1/2023. The last the document was updated was noted as January 17, 2022.
Staff #4 acknowledged the first aide/CPR listing posted was not current.

Plan of correction

Alerts will be sent via text and email to all staff members with CPR certifications expiring within 60 days of their renewal date. Additionally, monthly checks of postings will be conducted to prevent the recurrence of this issue. Date to be corrected: November 1, 2023

22VAC40-73-310-H

Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibition condition per the Code of Virginia 63.2-1805 D.

Evidence

On 10-23-23, resident #3’s record included a prescription dated 9-18-23 for Risperidone. The record did not include a psychotropic treatment plan for this medication.
Staff #4 acknowledged the resident’s record did not include a psychotropic treatment plan for Risperidone.

Plan of correction

Each new prescription will require a report copy to be sent to the Assistant Administrator, ensuring that the psychotropic treatment plan is updated. Additionally, staff members will document any new prescriptions in the new system when charting for the day. Date to be corrected: November 1, 2023

22VAC40-73-440-D

Based on record reviewed and staff interviewed, the facility failed to ensure the private pay uniform assessment instrument (UAI) was completed as require.

Evidence

Evidence:
On 10-23-23, resident #3’s UAI dated 10-3-23 was completed by facility staff #4, but not signed and dated by the administrator or designee.
Staff acknowledged, the resident’s UAI was not signed and dated by the administrator and/or designee.

Plan of correction

Each UAI must be communicated to the Assistant Administrator for her review and signature. RMAs who are responsible for completing the private UAI must submit the paperwork to the Assistant Administrator before filing it in the resident's chart. Date Corrected: November 1, 2023

22VAC40-73-450-F

Evidence

On 10-23-23, resident #3’s uniform assessment instrument (UAI) dated 10-3-23, bathing need was assessed as mechanical help/human help/physical assistance. The ISP dated 9-25-23 noted bathing as ?human and physical assistance---staff will supervise resident into the shower chair and stand by assist for safety?. Orientation noted resident disoriented some time to date and time; the ISP did not document what staff should do or how to assist the resident with this need.
Staff #2 acknowledged the UAI assessment and the ISP services were not the same.

Plan of correction

Each UAI must be communicated to the Assistant Administrator for review and signature. RMAs, responsible for completing the private UAI, must submit the paperwork to the Assistant Administrator before filing it in the resident's chart. This ensures that the ISP and UAI are appropriately aligned with each other. Date to be corrected: November 1, 2023

22VAC40-90-40-B

Based on the employee record review, the facility failed to ensure no employee was permitted to work in a position that involves direct contact with a resident until a background check was received as required in the Regulation for Background Checks for Assisted Living Facilities and Adult Day Care Centers (22VAC40-90), unless such persons works under the direct supervision of another employee for whom a background check has been completed in accordance with the requirements of the background check regulation (22VAC40-90).

Evidence

On 10-23-23, staff #5’s date of hire date noted as 10-4-23, first day of work noted as 10-9-23. The staff’s background check document was dated 10-11-23.
Staff #7’s date of hire date noted as 8-25-23 and the staff’s background check document was dated 9-18-25.
Staff #8’s date of hire noted as 9-21-23 and the staff’s background check document was dated 10-3-23.
The facility did not have documentation of the staff members being provided with sight and supervision of a staff with a criminal background check during the time the background check was not completed.

Plan of correction

It conveys that if the background check results are delayed, the new hires will undergo shadowing and hands-on training with side-by-side supervision to avoid licensing violations.

September 21, 2023Inspection11 violations

Inspection dates

Sept. 21, 2023 and Sept. 27, 2023

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments

Type of inspection: Monitoring An on-site Monitoring inspection conducted on 9-21-23 (Ar 07:40/dep 12:50 p.m). A medication pass observation conducted, breakfast and lunch meal observed, tour of the facility, resident and staff records reviewed. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The final exit meeting will be scheduled. 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 (Willie Barnes), Licensing Inspector at (757)-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-100-C-2

Based on observation and staff interviewed, the facility failed to ensure implementation of the facility’s infection control prevention measures was conducted.

Evidence

On 9-21-23 during the medication pass observation with staff #3, resident #3’s glucometer was not labeled with resident’s identifying information.
Staff #3 acknowledged the resident’s glucometer was not labeled.

Plan of correction

Colonial Manor has taken steps to address a citation by ensuring that all residents' personal equipment is properly labeled and cleaned according to infection control guidelines. This proactive approach is essential for maintaining a safe and hygienic environment for the residents and preventing future citations. Regular training and adherence to these guidelines will not only help in complying with regulations but also contribute to the overall well-being and health of the residents under their care. Date to be corrected: October 2, 2023

22VAC40-73-50-B

Based on record reviewed and staff interviewed, the facility failed to ensure the disclosure statement was provided to the resident and/or legal representative in advance of admission and prior to signing the admission contract.

Evidence

On 9-21-23, resident #1’s record did not include documentation of receipt of the disclosure statement. The resident’s date of admit noted as 6-8-23.

Plan of correction

1. It appears that there was a missing Disclosure Statement for a particular admission. To rectify the situation, the assistant to the Administrator took prompt action by completing the necessary form. Subsequently, the form was sent to the resident's guardian for their signature. This proactive approach ensures that all required documentation is in place and compliant with relevant regulations or procedures. Date to be corrected: September 21, 2023

22VAC40-73-70-A

Based on record reviewed, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or threatens the life, health or safety or welfare of any resident.

Evidence

On 9-21-23, resident #3’s progress note dated 8-21-23 document resident complained of chest and back pain. The resident was transported to the emergency room via 911 call.
Staff #2 stated sending an incident report, the licensing office have no report of an incident report for the aforementioned resident.

Plan of correction

22VAC40-73-310-D

Based on record reviewed and staff interviewed, the facility failed to ensure the administrator provided written assurance to the resident that the facility has the appropriated license to meet the needs of the care needs of the resident at the time of admission.

Evidence

On 9-21-23, resident #1’s record did not have signed documentation of having received written assurance from the administrator of the facility having the appropriate license to the meet the resident’s care needs at the time of admission. Resident’s date of admit noted as 6-8-23.

Plan of correction

1. It appears that there was a missing Written Assurance for a particular admission. To rectify the situation, the assistant to the Administrator took prompt action by completing the necessary form. Subsequently, the form was sent to the resident's guardian for their signature. This proactive approach ensures that all required documentation is in place and compliant with relevant regulations or procedures. Date to be corrected: September 21, 2023

22VAC40-73-310-H

Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibition condition per the Code of Virginia 63.2-1805 D.

Evidence

On 9-21-23, resident #3’s physician’s order dated 8-14-23 and September 2023 medication administration record (MAR) noted resident prescribed Paxil, start date of 3-13-23. The record did not include a psychotropic treatment plan.

Plan of correction

1. Providing education to Registered Medication Aides (RMA's) to ensure that all psychotropic medications have current treatment plans is a vital step in promoting the responsible and safe administration of such medications. Psychotropic medications can have significant effects on a resident's mental health, and having updated treatment plans is crucial for monitoring their usage and effectiveness while minimizing potential risks and side effects. Colonial Manor will demonstrate its commitment to resident safety and compliance with regulations. It also helps ensure that RMAs have the necessary knowledge and understanding to administer these medications responsibly and in alignment with the residents' treatment goals and needs. This proactive approach to medication management is essential in a healthcare setting. Date to be corrected: October 3, 2023

22VAC40-73-325-B

Based on record reviewed and staff interview, the facility failed to ensure the resident’s fall risk rating was reviewed at least annually, when resident condition changes and after a fall.

Evidence

On 9-21-23, resident #2’s record did not include an annual fall risk assessment, resident’s date of admit noted as 8-15-
The fall risk document in the record was dated 7-21-22.
Resident #3’s fall risk was dated 7-3-21. The fall risk dated “Dec 4/22” was signed by staff #1, but there was no assessment completed.

Plan of correction

Completing fall risk assessments and ensuring they are conducted annually for each resident is a crucial component of resident safety and regulatory compliance in healthcare settings. Falls can have serious consequences for residents, so proactive risk assessment and management are essential. Encouraging staff to routinely check each resident's chart for upcoming assessments is a practical approach to maintaining compliance with regulations and safeguarding residents' well-being. By implementing this process, Colonial Manor is demonstrating a commitment to proactive care and adherence to best practices in fall prevention. Regular assessments also allow for adjustments in care plans as needed, which can help mitigate fall risks and improve overall resident safety. This proactive and systematic approach to fall risk assessment and management is commendable and helps ensure a higher standard of care. Date to be Corrected: September 22, 2023

22VAC40-73-410-A

Based on record reviewed and staff interviewed, the facility failed to ensure the orientation for new residents and their legal representative included all the requirement information per the regulation.

Evidence

On 9-21-23, resident #1’s orientation documented 6-8-23 was not checked emergency response and mealtimes/menu provided. The document was not signed by the resident and/or legal representative, nor facility representative.
Staff #2 acknowledged the orientation form was not fully completed.

Plan of correction

1. Ensuring that all admission checklists are completed is a critical step in providing comprehensive care and adhering to regulatory requirements in healthcare settings. Colonial Manor has included these steps in the training provided to the admission team. This training helps ensure. 2. consistency and accuracy during the admission process, reducing the risk of oversights and ensuring that all necessary information and documentation are gathered. Date to be Corrected: September 22, 2023

22VAC40-73-440-H

Based on record reviewed and staff interviewed, the facility failed to ensure an annual reassessment and reassessment due to significant change in the resident’s condition, using the uniform assessment instrument (UAI), was utilized to determine whether a resident’s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.

Evidence

On 9-21-23, resident #2’s record did not have documentation of a current uniform assessment instrument (UAI). The UAI in the record was dated 8-30-22.
Resident #3’s UAI was dated 7-21-21 and 3-21-22.
Resident #2 and #3’s UAIs are private pay assessments.

Plan of correction

1. The Assistant to the Administrator is conducting a review of all ISPs and working on reviewing & completing the Individualized Service Plans (ISPs) for residents who have annual requirements that need to be fulfilled. Assigning a few staff to attend an ISP class. The goal is to have all ISPs updated within 45 days. Date to be Corrected: November 15, 2023

22VAC40-73-450-C

Based on record reviewed and staff interviewed, the facility failed to ensure the comprehensive individualized service plan (ISP) included all assessed needs.

Evidence

On 9-21-23, resident #1’s individualized service plan (ISP) dated 7-8-23 did not include resident’s pacemaker, noted on the resident’s physical examination and social data form. The resident’s physical examination dated 5-18-23, immunization record and facility interview noted wheat, iodine, and gluten allergies, these needs were not noted on the resident’s social data form. The resident was observed walking a cane. Staff #3 and #4 stated resident uses cane sometimes. The uniformed assessment instrument (UAI) dated 6-8-23 documented walking need as no help needed. Stairclimbing need assessed as no help needed, the ISP documented resident requires supervision with stairclimbing. Resident’s orientation assessed as disoriented some time, the spheres were not documented.

Plan of correction

1. It's important to ensure that Individualized Service Plans (ISPs) accurately reflect a resident's specific needs and medical conditions. Corrected the ISP plan for Resident #1 to include information about the pacemaker. Date to be Corrected: October 5, 2023 Additionally, if Resident #1 is using a cane for safety reasons, even without a physician's recommendation, it's crucial to assess the situation. The Assistant to the Administrator's request for an evaluation to determine the appropriateness of using a cane as a security measure is a proactive approach. It demonstrates a commitment to resident safety and well- being, as well as a willingness to adapt the care plan to the resident's specific needs. Evaluations by healthcare professionals can help ensure that the resident's use of the cane is both safe and effective. Date to be Corrected: October 15, 2023 Updating the Uniform Assessment Instrument (UAI) for Resident #1's walking needs and reassessing their orientation to reflect in the Individualized Service Plan (ISP) is a crucial step in providing personalized and responsive care. This ensures that the ISP accurately reflects the resident's current condition and needs. Integrating the updated UAI information into the ISP aligns the care plan with the resident's specific requirements and helps in delivering the most appropriate and effective services. Regular assessments and adjustments like these are essential for maintaining high standards of care and ensuring resident well-being. Date to be Corrected: October 5, 2023

22VAC40-73-450-F

Evidence

On 9-21-23, resident #2’s individualized service plan (ISP) was dated 8-20-22, the resident’s date of admit noted as 8- 15-17. Documentation in the resident’s record, last ISP noted resident occasionally wanders.
Resident #3’s ISP was dated 7-2-22. The resident’s date of admit noted as 3-7-17.

Plan of correction

The Assistant to the Administrator is conducting a review of all ISPs and working on reviewing & completing the Individualized Service Plans (ISPs) for residents who have annual requirements that need to be fulfilled. Assigning a few staff to attend an ISP class. The goal is to have all ISPs updated within 45 days. Date to be Corrected: November 15, 2023

22VAC40-73-610-C

Based on observations and staff interviewed, the facility failed to ensure the servings of the food listed on the menu met the current guidelines of the U.S. Department of Agriculture’s food guidance system or the dietary allowances of the Food and Nutritional Board of the National Academy of Sciences, taking into consideration the age, sex, and activity of the residents.

Evidence

On 9-21-23, during the lunch meal observation, the residents were served turkey sandwich, some resident received sliced apples, some received red grapes, and a few were served tortilla chips. Those who received grapes were served four grapes in a 2-ounce cup, those who were served sliced apples received 4- to 5 slices of a small apple. There were twenty residents present and six residents received tortilla chips. The menu noted chips to be served with the turkey sandwich. All residents were not provided every item from the menu. The administrator and staff #2 were asked if the facility had chips available to serve the residents. Staff #1 and #2 replied chips were available. Staff #2 went to the food storage area in another section of the building and showed the inspectors an open box of “tortilla chips”.
The facility nutritional report dated 3-28-23 and 4-4-23 documented the facility to use the diet manual provided for assist with menu and meal preparation and a menu planner checklist provided to staff # 2.
The administrator was informed, every resident should receive all items unless the resident declines an item. The administrator, staff #1 stated they, referring to the residents did not need to be given everything, they would not eat it, and the food gets thrown in the trash. This reminder is often noted in the nutritional reports provided to the facility.

Plan of correction

1. Training the dietary crew to provide the right amount of food for each resident, in accordance with the guidelines from the US Department of Agriculture's Food guidance, is crucial for ensuring residents receive proper nutrition and adhere to dietary requirements. Additionally, the practice of offering all meals as specified on the menu, unless a resident has allergies or dietary restrictions, is important for delivering a high standard of care. By implementing these guidelines and providing training to the dietary crew, Colonial Manor is demonstrating a commitment to both regulatory compliance and the well-being of its residents. Proper nutrition plays a significant role in maintaining residents' health and quality of life, and adherence to dietary guidelines ensures that their dietary needs are met. Substitution options for residents with allergies or dietary restrictions further enhance the facility's ability to accommodate individual needs and preferences. Date to be Corrected: October 10,2023

August 29, 2023Inspection14 violations

Inspection dates

Aug. 29, 2023 and Sept. 15, 2023

Areas reviewed

Comments

Type of inspection: Monitoring An on-site Monitoring Inspection conducted on 8-29-23 with two inspectors (LA/LI). AR (06:47 a.m./Dep 1:40 p.m). The facility census was 31. A final exit will be scheduled to review this inspection. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-100-C-2

Based on observation and staff interviewed, the facility failed to ensure implementation of the facility’s infection control prevention measures was conducted.

Evidence

On 8-29-23 during the medication pass observation with staff #3, resident #3’s glucometer was removed from its storage case and placed on top of a stack of papers located on the medication cart. The staff did not use gloves when administering the resident’s eye drops. The staff did not clean the resident’s nasal spray following intranasal use before returning it to its designated section of the medication cart. Staff administered resident #3’s eye drops without using gloves.
The large bottle of hand sanitizer on the medication cart was dated, 08/2021. The small bottle of hand sanitizer observed being used by staff #3 was dated 11/2018.

Plan of correction

Not published by VDSS.

22VAC40-73-70-A

Evidence

On 8-29-23, resident #1 observed confused and agitated. Resident stated return from the hospital the previous night (8- 28-23). The resident’s progress note did not document resident’s return. The resident’s progress notes in the record included a note dated 8-26-23 (11 a.m.) documenting the resident was sent to the hospital per resident’s request. A 4 p.m. documentation noted the resident was admitted to a local hospital-diagnosis of altered mental health.
The facility did not submit an incident report for resident #1’s admission to the hospital.

Plan of correction

1. The Assistant to the Administrator has introduced a new system for documenting incident reports. This system will streamline the process and enable timely submission of incident reports. Date to be Corrected: September 25, 2023 2. The Assistant to the Administrator has introduced a new system for documenting incident reports. This system will streamline the process and enable timely submission of incident reports. Date to be Corrected: September 25, 2023

22VAC40-73-250-D

Evidence

On 8-29-23, staff #6 `s record did not have documentation of the absence of TB in a communicable form. Staff’s date of hire noted as 8-16-23, first day of work noted as 8-18-23.
Staff #8’s record did not have documentation of the absence TB in a communicable form. Staff’s date of hire noted as 8-24-23.

Plan of correction

Not published by VDSS.

22VAC40-73-440-H

Based on record reviewed and staff interviewed, the facility failed to ensure that an annual reassessment and reassessment due to a significant change in the resident’s condition, using the UAI (uniform assessment instrument), shall be utilized to determine whether a resident’s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.

Evidence

On 8-29-23, resident #1’s record did not have documentation of an annual reassessment using the UAI to determine resident’s needs and continued placement in the facility. Resident #1’s private pay UAI in the record was dated 5-20-20 and 5-20-21. The resident’s date of admit noted as 10-8-2008.
Resident #2’s record did not include documentation of a UAI. The resident’s date of admit noted as 11-26-14.

Plan of correction

22VAC40-73-450-F

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plans (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.

Evidence

On 8-29-23, resident #1’s record did not include an annual ISP. The document in the record noted it was reviewed by staff #1 and noted “plan year May 2021” and ?revised Nov 7/22. The ISP also noted review date 5-20-22 and 11-7-22. Services to be re-evaluated 5-20-22. This same violation was cited on 2-10-23.
Resident #2’s record did not include an annual ISP. The resident’s date of admit noted as 11-26-14.
Resident #3’s ISP noted it was reviewed by staff #1 and noted “revised on Dec-17-22”, expected outcome dates 1-17-
es de t 3’s S oted oted ? e sed o ec ?, e pected outco e dates
Staff #2 acknowledged the ISPs for the residents -#1 and #2 were not corrected and updated following the 2-10-23 violation.

Plan of correction

Not published by VDSS.

22VAC40-73-610-B

Based on observation, the facility failed to ensure menus for meals and snacks for the current week was dated and posted in an area conspicuous to residents.

Evidence

On 8-29-23, the menu for meals posted was dated 8-17 to 8-23-23.

Plan of correction

The menu was posted in a timely manner. Based on observations from staff and other residents, it has been noted that some residents prefer to have a physical copy of the menu. To accommodate this preference, the facility will ensure that every resident has their own copy by Wednesday of each week. Additionally, the facility will install a covered bulletin board to protect the posted menu copies from being taken by others. Date to be Corrected: September 25, 2023

22VAC40-73-650-A

Based on record reviewed and staff interviewed, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment was started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over the counter, and sample medications.

Evidence

On 8-29-23, resident #2’s record did not have documentation of a physician or other prescriber’s orders for medications administered by staff #3 during the medication pass observation. Aripiprazole (MAR noted original date 9- 29-22, current written date 8-2-23). Progesterone (MAR noted start date 8-22-23). Citalopram (MAR noted original date 22-21-22, current written date 8-2-23). Bupropion (MAR start date 3-23-23). Buspirone- (MAR noted original date 8-2-19, current written 8-2-23).
Resident #3’s record did not have documentation of a physician or other prescriber’s orders for medications administered by staff #3 during the medication pass observation. Hydrochlorothiazide (MAR noted 7-31-23 start date). Diphenhydramine (MAR start date 4-17-23). Guaifen-PSE (MAR noted start date of 4-27-23, stop 8-21-23 and restarted 8- 21-23). Saline Nasal Spray (MAR start date 4-27-23). GNP eye drop (MAR start date 8-21-23).
Staff #5 came to the facility to assist in locating the physician’s orders but was not able to locate them.

Plan of correction

Outside facility providers typically send prescriptions directly to the pharmacy. To maintain the accuracy of the Medication Administration Record (MAR) in relation to the posted prescriptions in each resident's chart, the facility will now require a copy of the prescriptions to be faxed by outside providers. Date to be Corrected: September 25, 2023

22VAC40-73-660-A

Based on observation and staff interviewed, the facility failed to ensure the storage areas for the medications was locked.

Evidence

On 8-29-23 during the medication pass observation with staff #3, staff walked away from the medication cart leaving it unlocked as staff went to assist staff #8 with accessing the housekeeping cart from a nearby room. Staff also left the cup of medications for resident #2 on top of the medication cart.

Plan of correction

Not published by VDSS.

22VAC40-73-680-C

Based on record reviewed and staff interviewed, the facility failed to ensure medication was 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

On 8-29-23, resident #1’s August 2023 medication administration record (MAR) noted medications not administered according to the facility’s dosing schedule thirteen (13) days from August 2, 2023 to August 23, 2023.
Resident #2’s August 2023 MAR noted medications not administered according to the facility’s dosing schedule thirteen (13) days from August 4, 2023 to August 27, 2023.
Resident #3’s August 2023 MAR noted medications not administered according to facility’s dosing schedule fourteen (14) days from August 4, 2023, to August 27, 2023.

Plan of correction

Registered Medication Aides (RMAs) are undergoing training to ensure that they document in the resident's chart or leave a note if the resident chooses not to take their medication at the scheduled time. This is to prevent any missed medication notations on the Medication Administration Record (MAR). Date to be Corrected: September 25, 2023 22VAC40 73 710 B

22VAC40-73-710-B

Based on observation, record reviewed, and staff interviewed, the facility failed to ensure a medical restraint would only be used according to a physician’s written order and the written consent of the resident or the legal representative.

Evidence

On 8-29-23 during a tour of the facility with staff #1 and #2, resident #6’s bed was observed to have half-bed rails on both sides of the bed. The resident’s record did not include a signed physician’s order for use and no written consent of the resident or legal representative for this physical restraint.

Plan of correction

The facility will conduct a reassessment of the #6 resident's need for bed rail restraints and will obtain an order if necessary to ensure compliance with regulations. Date to be Corrected: October 2, 2023

22VAC40-73-860-I

Based on observation and staff interviewed, the facility failed to ensure that it stored cleaning and other hazardous materials in a locked area.

Evidence

On 8-29-23 during a tour of the facility with staff #1 and #2 hazardous materials were observed unlocked on the housekeeping cart located in the hallway near room #52. The facility provides services for residents with cognitive impairment.
Staff #1 acknowledged the hazardous items on the cleaning cart were not locked.

Plan of correction

The Administrator will arrange for the installation of a built-in door on the housekeeping cart. This measure is intended to ensure that residents with cognitive impairments are unable to access the cart. Date to be Corrected: October 15, 2023

22VAC40-73-870-A

Based on observation and staff interviewed, the facility failed to ensure the interior and exterior of the building was maintained in good repair and kept clean and free of rubbish.

Evidence

On 8-29-23, during a tour of the facility with staff #1 and #2, the metal/aluminum awning covering was observed to be loose and falling from the roofing structure in a few areas in the rear of the building. Staff #1 reached up and tried to push the metal/aluminum material back in place.
The floors in the dining areas were very sticky when walking on its surface.
The recessed light located over the fireplace continued blink during the inspection. This was brought to the facility’s attention during the 6-30-23 inspection. This was shown to staff #2.
The laminate floor at the entrance to room #24 is severely scuffed/scarred and discolored.

Plan of correction

1 . The Administrator has scheduled the maintenance crew to come and repair the ceiling in the courtyard and attend to any other necessary structural repairs to ensure compliance with regulatory standards. Date to be Corrected: October 15, 2023 2. The facility has hired a new housekeeping staff member who will be responsible for maintaining cleanliness on all floors, including the dining room. This measure is aimed at ensuring that the floors are clean and safe for all residents to walk on without the risk of falling. Date to be Corrected: September 25, 2023 The facility will consult an electrician to assess the lighting in the lobby. This light has been changed multiple times and requires further attention to ensure that it functions properly. Date to be Corrected: October 15, 2023 4. The facility has hired a new housekeeping staff member who will be responsible for maintaining cleanliness on all floors. This measure is aimed at ensuring that the floors are clean and safe for all residents to walk on without the risk of falling. Date to be Corrected: September 25, 2023

22VAC40-73-970-A

Based document reviewed, the facility failed to ensure that the fire and emergency evacuation drill frequency and participation was in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51).

Evidence

On 8-29-23, a check of the facility’s fire drills log did not include documentation of a fire and emergency evacuation drill for the month of July 2023.

Plan of correction

The administration will ensure that all training sessions are conducted on a monthly basis in compliance with the regulations for Assisted Living. Date to be Corrected: October 2, 2023

22VAC40-90-40-B

Based on the employee record review the facility failed to ensure no employee was permitted to work in a position that Description: Based on the employee record review, the facility failed to ensure no employee was permitted to work in a position that involves direct contact with a resident until a background check was received as required in the Regulation for Background Checks for Assisted Living Facilities and Adult Day Care Centers (22VAC40-90), unless such persons works under the direct supervision of another employee for whom a background check has been completed in accordance with the requirements of the background check regulation (22VAC40-90).

Evidence

On 8-29-23, staff #8 did not have a background check document in the record. The staff’s date of hire noted as 8-24-
Staff observed working without the supervision of another employee for whom a background check has been completed in accordance with the requirements of the background check regulations.
Staff #1 acknowledge the staff did not have a background check completed within 30 days and was not under the direct sight and sound supervision of another employee with a background check.

Plan of correction

1. The administration will ensure that background checks are conducted for all individuals before they can begin their job. Despite staffing shortages, this essential requirement had been temporarily overlooked to prioritize shift coverage and the onboarding of new hires. Date to be Corrected: September 25, 2023

August 29, 2023Complaint survey1 violation

Inspection dates

Aug. 29, 2023 and Sept. 15, 2023

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint An on-site Complaint Inspection was conducted on 8-29-23. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 8-22-23 regarding allegations in the resident care, staffing, supervision, and buildings and grounds. 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. Yes Number of resident records reviewed: Number of staff records reviewed: Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations area(s) of non-compliance with standard(s) or law was valid A violation notice was issued; any violation(s) not related to the complaint 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-280-A

Based on observation and interviews, the facility failed to ensure had staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by the resident assessments and individualized service plans, and to ensure compliance with this regulation.

Evidence

On 8-29-23, the facility census was thirty-one and there were two staff members available to provide medication and direct care needs. Resident #1 was observed agitated and requesting to use a phone. Record review, staff interview and resident interview determined the resident had a returned to the facility from a hospital stay. The resident would not provide the facility staff with a copy of the discharge documentation. Notes in the communication log documented there were medications changes but what specific medications were not documented. A review of the resident’s August 2023 medication administration record (MAR) documented resident prescribed Bupropion, Clonazepam, Adderall, and Venlafaxine. Resident #2 was agitated and wandering through the facility with a sweater smeared with fecal matter. A review of the resident’s chart documented resident cognitive impairment.
The direct care staff was diverted to the kitchen to prepare the breakfast meal because the cook walk-out. This is the second time the inspectors have come to the facility and direct care staff is in the kitchen preparing meals because there is no one to cook. On 6-30-23, the registered medication aide was administering medication and preparing the breakfast meal for 31 residents.
There was no activity staff available to provide activity during the inspector’s time at the facility.
The local transportation driver arrived to transport several residents to their day program but was delayed because the residents did not have breakfast, they were provided cold cereal. The residents were also waiting for their lunch to be prepared. Because there was no cook, the residents were prepared a bacon, lettuce and tomato sandwich and provided a rice Krispy treat and told to get a drink from the store at the day program.

Plan of correction

1. The Assistant to the Administrator will monitor the prescriptions of every resident returning to the facility from the hospital or any other clinic to ensure that the process is completed in a timely manner. Date to be Corrected: September 25, 2023 2. The Administrator will ensure that there is always enough staffing available to assist the residents. The Assistant to the Administrator will also re-train everyone to ensure that residents are properly dressed in clean clothing. Date to be Corrected: September 25, 2023 3. The Administrator will ensure there is backup staff available in case another staff member calls out. The Assistant to the Administrator will hire two dietary crew members for each shift to prevent any issues in case one of them calls out, ensuring that there is always a cook available. Date to be Corrected: September 25, 2023 4. Due to the staffing shortage, the activity was canceled. The administration will ensure that they post a notice of canceled activities when this issue arises in the future. Date to be Corrected: September 25, 2023 5. The Administrator will ensure there is backup staff available in case another staff member calls out. The Assistant to the Administrator will hire two dietary crew members for each shift to prevent any issues in case one of them calls out, ensuring that there is always a cook available. The facility will incorporate a lunch bag to be prepared the night before to ensure the availability of the packed lunch for everyone who goes to the day program. Date to be Corrected: September 25, 2023

July 31, 2023Inspection7 violations

Inspection dates

July 31, 2023 and Aug. 16, 2023

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments

Type of inspection: Monitoring An on-site monitoring inspection was conducted on 07-31-23 (AR 12:48 p/m./ Dep 5:00 p.m. The facility census was 31. The administrator was not present but arrive later during the inspection process. A tour of the facility was conducted, lunch meal observed, staff records reviewed. An exit meeting was conducted with the facility consultant and the administrator signed the Acknowledgment Form The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-200-E

Based on record reviewed and staff interviewed, the facility failed to ensure the facility had a written plan for supervision of direct care staff who have not yet met the requirements as allowed for in (22VAC40-730-C) for direct care qualifications.

Evidence

On 7-31-23, staff #6, was documented on the staff schedule as the direct care staff for the 6 a.m. to 2:30 p.m. shift. Staff #6’s record was reviewed for documentation of staff’s credentials for direct care training. The staff’s record did not have documentation of training for a direct care. This violation for this staff was also cited on 6-30-23. The staff was observe working alone as a direct care staff, there was no staff shadowing this staff. Staff stated just doing what staff knew to do for the resident who needed assistance with activities of daily living. Staff acknowledged not having any formal training or taking a class with an instructor.
The facility has residents whose needs including hoyer transfer lift, oxygen use, assistance with feeding and incontinent care. Staff #6’s record did not include training in these service needs areas. 3.This violation was cited 6-30-23 for the same staff.

Plan of correction

Staff #6 was identified as deficient for direct care training and had received the required training effective July 14, 2023, and the training certificate was signed off on by contracted individual. The training certificate had been placed in the file but may not have been reviewed by the reviewer at the time of the site visit. The certificate of training is attached. Staff #6 did receive orientation training on the care needs of facility residents including the use of the Hoyer transfer lift, oxygen use, and assistance with feeding and incontinent care. While some of these trainings were addressed in the training conducted by contracted individual, additional training such as oxygen use was conducted by qualified staff member of the facility. To prevent future violations of this regulation, the facility is developing a check sheet to document review of care plan/needs of each resident for each staff hired to worked with the resident. The care needs of each resident will be specifically addressed on the check sheet and signed and dated by each employee responsible for care of the resident. The check off sheet will be maintained in the training record of the employee with a code designated for the specific resident discussed. The resident code sheet will be maintained by the assistant to the administrator Each staff will receive a check off on each resident and documentation filed by October 31, 2023.

22VAC40-73-520-I

Based on observation, the facility failed to ensure the scheduled activity was provided.

Evidence

On 7-31-23, the activity schedule noted coffee and cookies at 2:00 p.m. There was no activity provided between 2:06 p.m. and 4:00 p.m.
This violation is a repeat from 6-30-23 monitoring.

Plan of correction

The Activities Coordinator has addressed the issue of following the scheduled and posted activities schedule with all staff. The Activities Schedule is regularly posted on the Bulletin Board along with the menu and other required activities. To prevent future violations of these regulations, staff will be required to document a review of the Bulletin Board postings at the beginning of each shift and sign off on an acknowledgment sheet prior to beginning their shift. Staff responsible for the implementation of the activities will document the completion of the activity daily. The Activities Coordinator will coordinate with staff weekly on the scheduled activities and monitor the sign-off sheets as well as the documentation of the activities. Each activity scheduled will be documented as completed or provide explanation why the activity is not accomplished. Any change of scheduled activity must be approved by the activity coordinator or the assistant to the administrator. All staff will be oriented on these requirements and the consequences of failing to implement these procedures. Orientation to be completed by September 1, 2023.

22VAC40-73-880-A

Based on interview, the facility failed to ensure at least one movable thermometer was available in the building for measuring temperature in individual rooms that do not have a fixed thermostat that shows the temperature in the room.

Evidence

On 7-31-23, the Air Conditioning (Cooling) unit was not operational in all areas of the facility. The facility staff was asked if there was a moveable thermometer to check the temperature of the rooms and common areas. Staff #2 stated that facility did not have a movable thermometer.
This is a repeat violation from the monitoring inspection conducted on 6-30-23 when the facility experienced AC (cooling) problems and was asked if a moveable thermometer was available in the facility to measure the temperatures in the facility.

Plan of correction

Individual rooms in the facility each have a working thermometer on the wall that reflects the temperature in the rooms. Due to the building being heated and cooled via units in zoned areas, the temperature does fluctuate as well as during periods when a zoned unit may not be functioning properly. To prevent future violations of this regulation the facility has purchased two (3) moveable thermometers with one also being capable of measuring the humidity inside the building. Staff will be trained on the use and storage location of these devices for use when necessary. Training of all staff will be completed by September 1, 2023.

22VAC40-73-880-C

Based on observation and staff interviewed, the facility failed to ensure the air conditioning unit was operational throughout the facility.

Evidence

On 7-31-23, during a tour of the facility with the administrator (staff #1), staff #2 #3 and CS-1, the Air Conditioning (AC) system was not operational throughout the facility. On the Residential Hallway, the AC was not operational in several residents? rooms, room #13, 17 and 27 were checked during the tour with facility administrator and consultant. 2 The AC in the small dining room across from the main dining room was not providing cool air to the residents as they
The AC in the small dining room across from the main dining room, was not providing cool air to the residents as they were gathered to watch TV.
The AC not operational throughout the building is a repeat violation from 6-30-23. The invoice provided on 7-13-23 noted cooling to public area, manager’s office and room 13.
The administrator acknowledged the AC unit was not operational in all areas of the building. This is a repeat violation from 6-30-23.

Plan of correction

The Administrator and agency HVAC vendor completed an evaluation of the room air conditioners in the facility and is in the process of developing a capital improvement plan to address HVAC concerns. The facility put in a new AC unit in Room #13. An AC Compressor was purchased for the AC unit in both rooms 17 and 27. AC components had been purchased and were awaiting arrival and installment to address the malfunctioning units in the dining areas. A follow-up review with the HVAC Vendor is scheduled for Thursday evening 8/24/2023 to assess corrective measures taken with the facility’s HVAC system. Individual room Acs currently functional.

22VAC40-73-890-B

the facility failed to ensure all interior was adequately lighted for safety and comfort of residents and staff.

Evidence

On 7-31-23, during a tour of the facility, the lights near rooms 5-6 and 17 and 18 were not lite.
Staff #1 (administrator) and CS-1 acknowledged the lights needed a bulb

Plan of correction

Bulbs were placed in the lighting fixtures for rooms 5-6, 17 and 18. The lights are currently functional. To prevent future violations of this regulation, the facility has hired an additional maintenance staff to monitor and perform required maintenance activities such as installing lighting, monitoring HVAC performance issues, and cleaning concerns. The staff is in the process of completing orientation but is already implementing improvements in cleaning and maintenance.

22VAC40-73-890-C

Based on observation and staff interviewed, the facility failed to ensure the glare was kept to a minimum in rooms used by residents by providing covering on the lights.

Evidence

On 7-31-23, during a tour of the facility with staff #1 (administrator, staff #2 and CS-1, the lights on the Residential Hallway was observed to not have a covering to reduce glare.
Staff #1 acknowledged the lighting did not have coverings.

Plan of correction

Lights in the Residential Hallway were recently installed but the covering for those units was falling and presenting a potential hazard to residents, employees, and visitors. Upon falling they would break or chip and replacements are not available. Therefore, the decision was made for safety reasons not to try replacing the defective coverings. This lighting is being included in the agency’s capital improvement plan to replace those recently purchased units with new lights. A plan to replace being reviewed with maintenance who will review alternatives to include cost and present to administrator within 45 days.

22VAC40-80-120-E-2

Based on observation and staff interviewed, the facility failed to ensure that the findings of the most recent inspections are posted in the facility.

Evidence

On 7-31-23, during the monitoring inspection, the inspections for 6-30-23, complaint and monitoring inspections were not posted.
On 6-30-23, during the monitoring and complaint inspection, the administrator was reminded of the requirements for the posting of all required inspections, not just the current Notice of Intent (NOI).

Plan of correction

The Assistant to the Administrator had posted the latest inspection in a binder, but the report was moved. To prevent future violations of this regulation, the Licensing Inspections will be posted in the foyer of the building near the sign-in roster with a visible post or announcement in the area pointing to the location of the Inspection Report. The Reports will be in a Binder on the Cabinet where the sign-in logs are located such that they are accessible to anyone wishing to review them.

June 30, 2023Complaint survey2 violations

Inspection dates

June 30, 2023 , July 18, 2023 and July 24, 2023

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 BUILDINGS AND GROUND

Comments

Type of inspection: Complaint An on-site complaint inspection conducted on 6-30-23 (AR 09:15/Dep 3:15) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 6-28-23 regarding allegations in the building and grounds area (pest control). Number of residents present at the facility at the beginning of the inspection: 32 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: Number of staff records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: collateral contact- consultants interviewed An exit meeting will be conducted to review the inspection findings. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-70-A

Based on document reviewed and staff interviewed, the facility failed to report the regional licensing office within 24 hours any major incident that has negatively affected or threatens the life, health, safety or welfare of any resident.

Evidence

On 6-30-23, staff #1 acknowledged the facility was being treated for bed bugs. The licensing office did not receive a report of residents being relocated because of the bed bugs in the facility.
Staff #1 acknowledged not reporting, the facility having bedbugs.

Plan of correction

Not published by VDSS.

22VAC40-73-870-D

Evidence

On 6-30-23, staff #1 acknowledged the facility was being treated for bed bugs. The licensing office did not receive a report of residents being relocated because of the bed bugs in the facility.
Staff #1 acknowledged not reporting, the facility having bedbugs. Based on documents reviewed and staff interviewed, the facility failed to ensure the building was kept free of infestations of insects and vermin. Evidence:
On 6-30-23, during a complaint inspection received on 6-28-23, regarding the facility having bedbugs, the inspector was informed, residents were relocated to another room after a cluster of bedbugs was discovered in the resident #1’s bedroom. Staff #1 and #3 stated residents #1 and #2 were relocated from room #21 to room #31 following discovery of bedbugs in room.
Staff #1 stated the residents were moved to another room and the room with the bedbugs was closed/sealed off from anyone entering.
On 6-30-23, inspector received copy of an invoice for bed bugs from staff #4 indicating bed bug service on 7-6-23.
On 7-18-23, interview with pest control consultant stated conducting treatment for bed bugs at the facility. According to consultant #3, the residents were relocated from room #21 where the bedbugs were located to another room. The room was closed off and the consultant returned to facility to conduct the first treatment on 7-6-23 with a follow-up for 7-11-23. The first treatment was conducted following payment concerns that needed to be addressed with the administrator prior to the beginning of treatment.

Plan of correction

Not published by VDSS.

June 30, 2023Inspection15 violations

Inspection dates

June 30, 2023 , July 13, 2023 and July 24, 2023

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments

Type of inspection: Monitoring An on-site monitoring inspection was conducted on 6-30-23 (AR 09:15/ Dep 3:25 P. The facility census was 32. The administrator was not present but arrive later during the inspection process. A tour of the facility was conducted, medication pass observed, lunch meal observed, staff and resident records reviewed. An exit meeting was conducted with the facility consultant and the administrator signed the Acknowledgment Form The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-120-A

Based on interview and record reviewed, the facility failed to ensure the orientation and training required in 22VAC40-73- 120-B and C of the regulation occurred within the first seven working days of employment. Until this orientation and training is completed, the staff person may only assume job responsibilities if under the sight supervisions of a trained direct care staff person or administrator.

Evidence

On 6-30-23, staff #6 and #7 record did not have documentation of orientation and training required per the regulation. Staff #6 date of hire noted as 6-5-23 and #7 date if hire noted as 6-19-23.

Plan of correction

Not published by VDSS.

22VAC40-73-200-E

Evidence

On 6-30-23, staff #5 and #9 did not have documentation of qualifications to provide direct care services to residents.
Staff #9 stated not have documentation of paid work or volunteer work with adults who are aged, infirm or disabled. Staff #9’s record did not have documentation or certification of direct care training. Staff observed spoon-feeding a resident during the lunch meal on 6-30-23.
Staff #5 stated working with adults in another state but did not have certifications of prior training in the record.

Plan of correction

Not published by VDSS.

22VAC40-73-250-C

Based on record reviewed and staff interviewed, the facility failed to ensure the staff’s personal record include verification that the staff person had received a copy of the current job description.

Evidence

On 6-30-23, staff #6, #7 and #8 did not have a signed and dated copy verifying receipt of a job description.

Plan of correction

Not published by VDSS.

22VAC40-73-310-D

Based on record reviewed and staff interviewed, the facility failed to ensure, prior to admission the assisted living facility, the administrator provided written assurance to the resident that the facility has the appropriate license to meet the care needs at the time of admission. A signed copy by the resident and or legal representative shall be kept in the resident’s record.

Evidence

On 6-30-23, resident #1’s record did not have documentation of the written assurance. The resident’s date of admit was noted as 1-5-23.
Resident #2’s record did not have documentation of the written assurance. The resident’s date of admit was noted as 6-8-23.
Resident #3’s record did not have documentation of the written assurance. The resident’s first date of trial visit (respite stay) was noted as 1-25-23.

Plan of correction

Not published by VDSS.

22VAC40-73-320-A

Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s physical examination and risk assessment was completed prior to admission.

Evidence

On 6-30-23, resident #3’s physical examination was dated 10-4-22 and the tuberculosis (TB) risk assessment was dated 3-28-23. The resident’s first day of stay in the facility was dated 1-25-23. The resident is on trial visit stays from a local mental health facility.
Resident #1’s admitting physical was dated 11-30-22. The resident’s date of admit was noted as 1-5-23.
Resident #2’s TB assessment was dated 4-18-23. The resident’s date of admit was noted as 6-8-23.

Plan of correction

Not published by VDSS.

22VAC40-73-410-A

Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s record included acknowledgment of having received orientation to the facility’s emergency response procedures, mealtimes, and use of the call system (signaling device).

Evidence

On 6-30-23, resident #1’s record did not have documentation of orientation to the facility. The resident’s date of admit noted as 1 5 23 noted as 1-5-23.
Resident #2’s record did not have documentation of orientation to the facility. The resident’s date of admit noted as 6- 8-23.
Resident #3’s record did not have documentation of orientation to the facility. The resident’s first date of trial visit (respite stay) was noted as 1-25-23.

Plan of correction

Not published by VDSS.

22VAC40-73-440-E

Based on record reviewed and staff interviewed, the facility failed to ensure for public pay individuals, the uniform assessment instrument (UAI) was completed by the case manager or qualified assessor.

Evidence

On 6-30-23, resident #3’s record did not have documentation of a completed UAI. The resident record noted resident is being provided trial visit (respite) services. The resident’s record noted the resident stay is 48 hours per visit.

Plan of correction

Not published by VDSS.

22VAC40-73-450-A

Based on record reviewed and staff interviewed, the facility failed to ensure the preliminary plan was signed and dated by the licensee, administrator, or his designee, and by the resident or legal representative.

Evidence

On 6-30-23, resident #2’s preliminary plan of care in the record was not signed and dated by the resident and/or legal representative. The resident’s date of admit was noted as 6-8-23.

Plan of correction

Not published by VDSS.

22VAC40-73-450-C

Based on record reviewed and staff interviewed, the facility failed to ensure that there was an individualized service plan (ISP) for a resident.

Evidence

On 6-30-23, resident #3’s record did not have a signed and dated ISP with assessed needs. The record noted the resident have been completing trial visits (respite services) from a local mental health facility. The record noted services (trail visits) began on 1-25-23.
Resident #1’s uniform assessment instrument (UAI) dated 2-7-23 noted bathing assessed as human help/physical assistance. The ISP dated 2-5-23 noted resident uses a shower chair during bathing time. Toileting assessed as human help/supervision. The ISP noted resident uses the grab-bars during toileting. Transfer is not noted on the UAI. The ISP noted resident uses arms or chairs/ grab-bars and staff provides supervision. Bowel is assessed as independent. The ISP noted staff provides supervision. The record also noted physical/occupational /speech evaluation order dated 1-12-23. This information was not documented on the ISP.

Plan of correction

Not published by VDSS.

22VAC40-73-520-I

Based on observation and staff interviewed, the facility failed to ensure that the activity noted on the schedule was provided.

Evidence

On 6-30-23, the activity calendar posted noted, “Table Volleyball” scheduled for 9:30 a.m. There was no activity or substitution of an activity provided to the residents present on the morning of 6-30-23.

Plan of correction

Not published by VDSS.

22VAC40-73-560-I

Based on record reviewed and staff interviewed, the facility failed to ensure a current picture of a resident was readily available for identification purposes or, if the resident refuses to consent to a picture, there shall be a narrative physical description, which is annually updated and maintained in the resident's file.

Evidence

On 6-30-23, resident #3’s record did not have a current picture of identification in the record. The record also did not include a narrative physical description of the resident. The resident trial visit (respite stay) first day of stay was noted as 1-25-23.

Plan of correction

Not published by VDSS.

22VAC40-73-870-E

Based on observation and staff interviewed, the facility failed to ensure the furnishings, fixtures, and equipment shall be kept clean and in good repair and condition kept clean and in good repair and condition.

Evidence

On 6-30-23, the bottom kitchen shelf was observed with clear plastic with heavy soiled brown substance. There were food and serving items on this plastic sheet.
The ceiling area where the camera is in the kitchen is loose and not flushed and grounded to the ceiling.
The wall behind the hand sink area sheet rock is missing. The drainpipe underneath the hand sink is not connected. There is a bucket underneath the sink to catch the water. Staff stated the floor area is sometimes flood from the water that is released from the disconnected drainpipe.
Staff #3 acknowledged the areas of the kitchen was not maintained in good repair. The area was also observed by consultant #1 on 6-30-23.

Plan of correction

Not published by VDSS.

22VAC40-73-880-A

Evidence

On 6-30-23, the Air Conditioning (Cooling) unit was not operational in all areas of the facility. The facility staff was asked if there was a moveable thermometer to check the temperature of the rooms and common areas. Staff #3 stated that facility did not have a movable thermometer. The staff was asked if there was a meat thermometer or water temperature thermometer available. The staff response was no.

Plan of correction

Not published by VDSS.

22VAC40-73-880-C

Based on observation and staff interviewed, the facility failed to ensure the air conditioning unit was operational throughout the facility.

Evidence

On 6-30-23, upon entering the facility kitchen, the backdoor was observed to be propped open with a chair. Staff #3 stated the AC did not work.
The front entrance door was also observed propped open when the inspectors arrived at 09:15 a.m. The front entrance/common area did not have AC working.
On 6-30-23, staff #1 stated the unit was not working on 6-23-23. There are 6 total units, and 4 units were working. Staff stated, ?the extractor was not sufficient in refrigeration room, this has to be changed, 1 unit needed to be repaired and 2 units needed to be replaced?.
On 7-13-23, the invoice for the AC was submitted to inspector included AC unit replacement and other repairs to the facility’s AC system.

Plan of correction

Not published by VDSS.

22VAC40-90-40-B

Evidence

On 6-30-23, staff #7 did not have a background check document in the record. The staff’s date of hire noted as 6-19- 23.

Plan of correction

Not published by VDSS.

May 4, 2023Inspection15 violations

Inspection dates

May 4, 2023 and May 31, 2023

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

Comments

Type of inspection: Monitoring An unannounced monitoring inspection conducted by two inspectors (LA/LI) on 5-4/2023 (Ar 10:50 a.m/dep 4:40 p.m.) The facility census was 32. A tour of the facility was conducted, the lunch meal was observed, staff and residents? records reviewed. The administrator was not present but arrived later and signed the Acknowledgement Form. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A final exit meeting will be scheduled. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-50-B

Based on record reviewed and staff interviewed, the facility failed to ensure it prepared and provide a statement to the prospective resident and the legal representative, if any, that discloses information about the facility. Documentation of the acknowledgement should be in the resident’s record.

Evidence

On 5-4-23, resident #1’s record did not have written documentation of having received the facility’s disclosure document. The resident’s date of admit noted as 1-21-23.

Plan of correction

Not published by VDSS.

22VAC40-73-140-E

Based on record review and staff interviewed, the facility failed to ensure administrators who supervise medication aides shall be required to annually have four hours of training in medication administration specific to the facility population or a refresher course in medication administration offered by the Virginia Board of Nursing approved program.

Evidence

On 5-4-23, staff #1’s record did not have documentation of the medication refresher course. Staff #1 supervises the registered medication aides in the facility. Staff’s date of hire is unclear, 1-5 2005 or 1999.

Plan of correction

Not published by VDSS.

22VAC40-73-210-B

Based on record reviewed and staff interviewed, the facility failed to ensure staff in a facility licensed for both residential and assisted living care, staff shall attend at least 18 hours of training annually.

Evidence

On 5-4-23, staff #1’s record noted only 12 hours of dementia training (3-2-22). The record did not include the required infection control training.

Plan of correction

Not published by VDSS.

22VAC40-73-260-A

Based on documents reviewed and staff interviewed, the facility failed to ensure staff maintained current certification in first aid.

Evidence

Staff #1 did not have documentation of a current certification in first aid.

Plan of correction

Not published by VDSS.

22VAC40-73-310-B

Based on record reviewed and staff interviewed, the facility failed to ensure a documented interview between the administrator or a designee responsible for admission and retention decision, the individual and legal representative, if any.

Evidence

On 5-4-23, resident #2’s record did not have documentation of an interview and mental health assessment for admissions.

Plan of correction

Not published by VDSS.

22VAC40-73-310-D

Based on record reviewed and staff interviewed, the facility failed to ensure it provided written assurance to the resident and the legal representative, if any, that it had the appropriate license to meet the resident’s care needs at the time of admission.

Evidence

On 5-4-23, resident #1’s record did not have documentation of having received and signed the facility’s acknowledgement of being provided written assurance it had the appropriate license to meet the resident’s need at the time of admission. The resident’s date of admit was noted as 1-21-23.

Plan of correction

Not published by VDSS.

22VAC40-73-410-A

Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s record included written acknowledgement of orientation for new residents.

Evidence

t #1?
On 5-4-23, resident #1’s orientation document in the record was not signed and dated by resident or legal representative. Resident’s date of admit noted as 1-21-23.
Resident #2’s orientation document in record was incomplete and not signed by resident, legal representative and neither by facility representative. Resident’s date of admit noted as 1-15-23.

Plan of correction

Not published by VDSS.

22VAC40-73-440-D

Based on record reviewed and staff interviewed, the facility failed to ensure that for private pay individuals the assisted living facility shall ensure that uniform assessment instrument (UAI) was in compliance as required by 22VAC30-110.

Evidence

On 5-4-23, resident #2’s uniform assessment instrument (UAI) dated 1-6-23 was not completed per the requirements. The document was also not signed and dated by the assessor and the facility reviewer. The resident’s date of admission was noted as 1-5-23.

Plan of correction

Not published by VDSS.

22VAC40-73-450-B

Based on documents reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was completed by the licensee, administrator, or the designee who has successfully completed the department-approved individualized service plan (ISP) training, provided by a licensed health care professional practicing within the scope of his profession.

Evidence

On 5-4-23, resident #1’s individualized service plan (ISP) dated 1-24-23 and 2-24-23 was developed by staff #2. The ISP should be completed by the licensee, administrator or designee who has successfully completed the department approved individualized service plan (ISP) training provided by a licensed healthcare professional practicing within the scope of her profession. Staff #2 did not have ISP training at the time of the ISP development.
Resident #2’s ISP dated 1-5-23 and 2-5-23 was completed by staff #2, a person not authorized to complete the ISP.

Plan of correction

Not published by VDSS.

22VAC40-73-470-A

Based on record reviewed and staff interviewed, the facility failed to ensure, either directly or indirectly, that the health care service needs of residents are met.

Evidence

On 5-4-23, resident #1’s record included prescriber’s order dated 2-15-23 for “ PT/OT evaluate”. The resident’s record did not include documentation of service being conducted and the services were not documented on the resident’s ISP dated 2-24-23.

Plan of correction

Not published by VDSS.

22VAC40-73-520-I

Based on observation and staff interviewed, the facility failed to ensure the current month’s activity schedule shall be posted in a conspicuous location in the facility or otherwise be available to residents and their families.

Evidence

On 5-4-23, during a tour of the facility, the activity calendar posted on the bulletin board across from staff breakroom was for the month of April 2023.
Staff #3 acknowledged the current month’s calendar was not posted on 5-4-23.

Plan of correction

Not published by VDSS.

22VAC40-73-550-G

Based on record reviewed and staff interviewed, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities was reviewed annually with each staff person with written acknowledgement of having been informed, which shall include the date of the review and shall be filed in staff person’s record.

Evidence

Staff #1’s record did not have documentation of review of resident’s rights and responsibilities.

Plan of correction

Not published by VDSS.

22VAC40-73-610-C

Evidence

On 5-4-23, during the lunch meal observation, the residents were served coleslaw and peaches in 3.25 fluid oz cups (96.1ml), the same cup used to serve the condiments (ketchup and mayonnaise). The coleslaw cups were half-full. Based on observations, staff #5 was asked if the dietary manual was available, so that the correct serving amount could be determined. The residents were served three small fish sticks, french fries, and 1-2 sliced tomatoes and lettuce.
The facility nutritional report dated 3-28-23 and 4-4-23 documented the facility to use the diet manual provided for assist with menu and meal preparation and a menu planner checklist provided to staff #2.

Plan of correction

Not published by VDSS.

22VAC40-73-860-I

Based on observations and staff interviewed, the facility failed to ensure that it stored cleaning supplies and other hazardous materials in a locked area.

Evidence

On 5-4-23 during a tour of the facility with staff #2, cleaning products- washing liquids were located in the unlocked laundry room near the nursing station. In the common area, the future dining room for the safe, secure unit, high traffic floor polish was located in the common bathroom and floor cleaner was also located in the dining area near the closet.

Plan of correction

Not published by VDSS.

22VAC40-73-870-E

Evidence

On 5-4-23 during a tour of the facility, the secure sealant to the pipe/tubing for the hot water heater locater in the laundry room near the nursing station was coming apart from the ceiling. The metal/stainless steel was not sealed/flushed and grounded to the ceiling. The right corner of the counter in room #47 is missing portion of the formica and the door is missing from the cabinet above the right side of the sink, the hood contains brown colored substance. The toilet in the dining area on the safe, secure unit was missing the top to the toilet seat and the shower was missing the shower head. The bathtub in room #17 is in need of repair- resurfacing. The refrigerator in the food storage room near the administrative office was in need of cleaning, brown liquid substance on shelves.

Plan of correction

Not published by VDSS.

February 10, 2023Complaint survey5 violations

Inspection dates

Feb. 10, 2023 and May 31, 2023

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND

Comments

Type of inspection: Complaint An unannounced complaint inspection conducted on 2-10-23 LI and LA (A2r 09:15 dep/ 1:45 p). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2-3-23 regarding allegations in the resident care and related services and buildings and grounds and nutrition. Number of residents present at the facility at the beginning of the inspection: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law. A violation notice was issued; any violation(s) not related to the complaint 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-280-A

Evidence

On 2-10-23 during a complaint inspection, the direct care staff scheduled provided noted one direct care staff schedule on multiple days and shifts to provide services. The facility census on 2-10-23 was thirty-three. The facility has residents assessed at the assisted living level of care requiring assistance with bathing, feeding, incontinent care and transferring. The facility has residents who are non-ambulatory, receiving hospice services and oxygen care. The is one staff to administer the medication from two medication carts.
The direct care staff schedule provided on 2-10-23 dated 1-29 to 3-11-23 noted multiple days and shifts with one or no working. The direct care staff schedule dated 1-29 to 2-11-23 noted (6a- 2:30 p shift) noted one staff twelve days and 2p to 10:30p shift noted one staff seven days. The schedule dated 2-12 to 2-25-23 (6a-2:30 p shift) noted one staff fourteen days and 2- to 10:30p shift noted one staff 8 days. The schedule dated 2-26 to 3-11-23 (6a-2:30p shift) noted one staff fourteen days and 2p to 10:30p shift noted one staff eight days. The schedule dated 1-19 to 3-11-23 did not have documentation of direct care staff working on the following dates and shift: 2-3, 2-5, 2-17-, 3-3, 3-4, 3-5, 3-6-23 (6a-2:30 p and 2-10:30p). The schedule did not have a direct staff on the following dates and the 2p to 10:30p shift (2-12 and 2-26- 23).

Plan of correction

Not published by VDSS.

22VAC40-73-440-H

Based on record reviewed and staff interviewed the facility failed to ensure an annual reassessment and reassessment due to a significant change in the resident’s condition, using the uniform assessment instrument (UAI) was utilized to determine whether a resident’s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident facility is in the best interest of the resident.

Evidence

On 2-10-23, resident #2’s private pay UAI in the record was dated 5-20-20 and 5-20-21. The record did not include a current UAI. The resident’s date of admit noted as 10-8-2008.

Plan of correction

The Provider did not provide a Plan of Correction

22VAC40-73-450-B

Evidence

On 2-10-23, staff #1 was asked to provide documentation of Uniform assessment instrument (UAI) and ISP training. Staff did not provide documentation of UAI and ISP training.
Staff #1 completed ISP for residents? record reviewed, which were not completed correctly.

Plan of correction

Not published by VDSS.

22VAC40-73-450-F

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.

Evidence

On 2-10-23, resident #1's individualized service plan (ISP) noted and end 10-15-22 date/review date of 10-15-22 and 11- 6-22. Staff #1 staff updated all resident’s service plan. The plan was not updated, but it did note staff #1’s signature at the top of the first page of the ISP with a
Resident #2’s ISP was dated “plan year May 2021” and ?revised Nov 7/22. The ISP also noted review date 5-20-22 and 11-7-22. Services to be re-evaluated 5-20-22.
Interview with staff #1 revealed staff did not have documentation of UAI and ISP training. Staff stated going through the training a while back.

Plan of correction

Not published by VDSS.

22VAC40-73-870-E

Evidence

On 2-10-23 during a tour of the facility, the dryer in the laundry room near the nursing station was not working. There was another dryer that did not heat, according to staff. The dryer also made a lot of noise when turned on as evidence by the noise heard when the inspector was on the tour with staff #4.

Plan of correction

Not published by VDSS.

July 20, 2022Complaint survey8 violations

Inspection dates

July 20, 2022 , July 28, 2022 and Aug. 25, 2022

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint An unannounced complaint inspection conducted by two inspectors (ERO/PLO) on 7-20-22. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 7-11-22 regarding allegations in the staffing and resident care and related services (food- medication- wandering/elopement) Number of residents present at the facility at the beginning of the inspection: Facility census was 35 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings on August 15, 2022 and August 22, 2022 The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-70-A

Based on record reviewed and staff interviewed the facility failed to report to the licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.

Evidence

On 7-20-22 during a complaint inspection regarding resident #1’s elopement from the facility and found in the community, interviews with staff members and collateral interview confirmed the resident was not present in the facility for a period of time and was returned by someone from the community. Following knowledge of the resident’s elopement from the facility, the resident’s individualized service plan (ISP) was updated on 5-2-22 for staff to conduct 30 minute checks for the resident’s safety. Prior to this event, the resident’s record documented on 5-21-21, concerns regarding the resident wandering outside the facility. The concern was also presented to the resident’s treating physician for evaluation of medication. The resident’s progress notes documented multiple occasions of resident being observed outside of the facility without staff from May 2021 to April 17, 2023. The uniform assessment instrument (UAI) dated 27-22 assessed the resident as a wandering greater than weekly. The ISP dated 2-11-22 documented staff to monitor resident because of wandering behavior. The resident’s record did not document the recent elopement. Interviews with facility staff stated being aware of the elopement incident but did not document incident in resident’s record. The facility also did not complete an incident report following knowledge of the resident leaving the facility and being returned by a person from the community. Staff #3, #4. #5 and #9 were interviewed and acknowledged resident left facility and was returned by an individual from the community.
Resident #1’s record documented additional incidents that were not reported to the licensing office. On 4-16-22 (7 am), staff documented ?resident found on floor...left knee, left hand as well as face had bruising, scratch on left shoulder as well, sent out to hospital. Resident’s discharge summary from the hospital documented: contusion of face (left side) and contusion of dorsum of hand (left hand). The resident’s record also included a ?resident incident/accident form documenting resident found face down on the floor with both knees swollen...bruises on the face, left side and hand, scratches on left shoulder.
Resident’s discharge summary from local hospital on 4-27-22, documented head injury with staples received to be removed in 7 days by primary care provider, clean area of the wound twice daily with soap water, may apply a small amount of bacitracin for the next 2-3 days after cleaning. Reason for visit: fall/ head injury. Diagnoses: closed head injury/scalp laceration. Nurse’s notes on 4-30-22 at (7 p.m.) documented CS-1 did resident #1’s wound care on her head. The record also included a transfer form dated 4-27-22 documenting, “resident has a dash on top of resident’s head”.
On 8-15-22, staff acknowledged incident reports were not reported for the aforementioned resident as required.

Plan of correction

Administration acknowledges procedural failures due to change in staff designated to make reports. Procedural changes implemented whereby all incidents will be filtered through new assistant to the Administrator to ensure timely reports are made. All staff has been informed of the requirement to report all activities defined as reportable incidents to the assistant to the administrator immediately. Assistant assumes responsibility with the administrator to ensure all incidents are reported within 24 hours of occurrence. Resident undergoing review and evaluation for an update of plan of care or proper placement. In addition to disciplinary actions, staff undergoing additional training and evaluations. Person Responsible: Administrator, Assistant to Administrator, Agency Contracted Nurse, Consultant

22VAC40-73-280-A

Based on documents reviewed and interviews, the facility failed to ensure it had staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well- being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with the regulation.

Evidence

On 7-20-22 during a complaint inspection, the inspector observed two staff person in the facility. Upon interviews with staff #7 and #8, neither staff was trained to administer medications. According to staff, the medication room was off limits. If someone needed something staff would have to contact staff #2.
Resident #2 interviewed and stated not receiving morning medications because there is no one in the facility to give out medications. The resident’s July 2022 medication administration record (MAR) included the following medications to be administered at 04:00 a.m.: (1) Cyclobenzaprine,( 2) Gabapentin and (3) Ibuprofen. The resident did not receive medication on July 20, 2022, when the inspector arrived, there was no one in the facility authorized to administer medications.
The facility’s July 3 to August 13, 2022 registered medication aide (RMA) schedule did not have a staff scheduled on the 10:00 p.m. to 6:30 a.m. shift on 7-5-22, 7-9-22 and 7-19-22.

Plan of correction

The administration acknowledges an inadequate number of Registered Medication Aides and currently has four (4) staff in training to complete the Medication Aide training class during the week of August 29, 2022. The facility has hired one (1) trained Registered Medication Aide who is licensed as an RMA. To prevent future violations of this standard, the administration will continuously advertise for Registered Medication Aides as well as obtain an additional training vendor to enhance the timeliness of training completion of those hired. Once the four (4) currently hired staff is provisionally licensed, the facility, with oversight of contract nurse, shall be able to staff time slots and prevent any missed medications. In addition, the resident with 4:00 AM administration of medication was changed to 6:00 AM medication scheduled. Person Responsible: Administrator and Assistant to Administrator, Agency Contracted Nurse

22VAC40-73-320-B

Complaint related:

Evidence

On 7-20-22 during a complaint inspection, resident #2’s TB document was dated 6-8-21, resident’s date of admission was documented as 8-15-17.
On 8-15-22, staff acknowledged the aforementioned resident’s TB was not updated.

Plan of correction

The assistant to the Administrator and agency Contracted Nurse are addressing TB Risk Assessments for resident #2. To prevent future violations of this standard, the Administrator, Assistant to the Administrator an Agency Contracted Nurse and an assistant are reviewing 100% of resident files to identify those in need of annual risk assessment. Person Responsible: Administrator, Assistant to Administrator, Agency Contracted Nurse

22VAC40-73-325-A

Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s fall risk rating shall be reviewed and updated when the condition of the resident changes and after a fall.

Evidence

On 7-20-22 during a complaint inspection, resident #1’s nurse’s notes dated 4-16-22 (7 a.m.), documented resident fell and was sent to the hospital. The record also included a discharge summary date 4-27-22 from a local hospital, documenting resident seen and treated for a fall. The risk rating in the record on 7-20-22 was dated 2-11-22.
On 8-15-22, staff acknowledged the fall risk rating was not completed for the aforementioned resident following each fall.

Plan of correction

Agency Contracted Nurse, Activities Coordinator, and Assistant to Administrator are reviewing records of resident #1 to review falls and the need for updated risk ratings. Agency Contracted Nurse will update risk assessment on residents requiring update. To prevent future violations of this standard, the staff will notify assistant to administrator of all falls immediately. Assistant to administrator will submit incident reports to DSS Licensing and meet with agency Contracted Nurse to have updated risk rating completed. Agency Contracted Nurse will complete an updated risk rating within 72 hours of fall. All falls will be reviewed by the Administrator, Assistant to Administrator, Agency Contracted Nurse, Activities Coordinator, and RMAs weekly. Weekly reviews will be documented. Person Responsible: Agency Contracted Nurse, Activities Coordinator and Assistant to Administrator

22VAC40-73-440-D

Based on record reviewed and staff interviewed, the facility failed to ensure for a private pay individual, the Uniformed Assessment Instrument (UAI) is completed as required 22VAC30-110.

Evidence

On 7-20-22, during a complaint inspection, resident #1’s UAI dated 2-7-22 was not signed by the designee or administrator.
On 8-15-22, staff acknowledged the aforementioned UAI was not signed and dated as required.

Plan of correction

The nurse and Assistant to Administrator are addressing the update of UAI for residents #2 and 6. To prevent future violations of this standard, the Administrator, Assistant to Administrator, and Agency Contracted Nurse are reviewing 100% of all resident records to assess the need for updated UAI. A monthly log of UAI updates needed will be maintained by the Assistant to Administrator and Agency Contracted Nurse to ensure UAIs are updated timely. In addition, the facility is training two additional staff to complete UAIs to assist nurse in meeting update deadlines. Person Responsible: Administrator, Assistant to Administrator, Agency Contracted Nurse, Activities Coordinator and RMA

22VAC40-73-440-H

Based on record reviewed and staff interviewed, the facility failed to ensure an annual reassessment or reassessment due to a significant change is completed using the UAI, to determine whether a resident’s needs can continue to be met at the facility and whether continued placement in the facility is in the best interest of the resident.

Evidence

On 7-20-22 during a complaint inspection, resident #2’s UAI was dated 8-18-20. The resident’s date of admit was documented 8-15-17.
On 8-15-22, staff acknowledged the aforementioned resident’s UAI was not completed annually as required.

Plan of correction

The nurse and Assistant to Administrator are addressing the update of UAI for resident #2. To prevent future violations of this standard, the Administrator, Assistant to Administrator and Agency Contracted Nurse are reviewing 100% of all resident records to assess need for updated UAI. A monthly log of UAI updates needed will be maintained by Assistant to Administrator and Agency Contracted Nurse to ensure UAIs are updated timely. In addition, the facility is training two additional staff to complete UAIs to assist nurse in meeting update deadlines. Person Responsible: Administrator, Assistant to Administrator and Agency Contracted Nurse, Activities Coordinator and RMA

22VAC40-73-450-F

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed as the condition of the resident changes reviewed and updated at least once every 12 months and as needed as the condition of the resident changes.

Evidence

On 7-20-22, during a complaint inspection, resident #2’s individualized service plan (ISP) was dated and signed by the developer on 8-18-20. The end/review date was documented as 8-18-21.
On 8-15-22, staff acknowledged the aforementioned resident’s ISP was not updated as required.

Plan of correction

Agency Contracted Nurse is reviewing resident #s 2 treatment plan for update. A treatment plan will be appropriately updated after consultation with resident’s treatment practitioner. To prevent future violations of this standard, the administrator, assistant to the administrator, Agency Contracted Nurse, Activities Coordinator and RMAs are reviewing 100% of all resident’s records to identify those requiring updated treatment plans. The review will be documented and plans requiring updates will be accomplished. Any resident who discharges from or leaves the facility for an extended period of time will have an updated treatment plan completed upon reentry. In addition, the Administrator, Assistant to Administrator, Agency Contracted Nurse, Activities Coordinator and RMAs will meet weekly to review residents requiring updated treatment plans. Agency Contracted Nurse will ensure updated plans are accomplished. Weekly reviews will be documented. Person Responsible: Administrator, Assistant to Administrator, Agency Contracted Nurse, Activities Coordinator and RMAs

22VAC40-73-680-C

Based on documents reviewed and staff interviewed, the facility to ensure medications shall be administered not earlier than one hour before and not later than on 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

On 7-20-22, resident #3’s July 2022 medication administration record (MAR) documented resident did not receive the following medications in accordance with the facility dosing scheduled during the month of July 2022: (1) Artificial tears, (2) Aspirin 81 mg, (3) Atorvastatin, (4) Cyclobenzaprine, (5) Famotidine, (6) Gabapentin, (7) Ibuprofen, (8) Levetiracetam, (9) Metoprolol Tartrate, (10) Omeprazole, (11) One-Tab daily w/minerals, (12) Phenobarbitol and (13) Zonisamide
Resident #4 did not receive the following medication in accordance with the facility’s dosing scheduled during the month of July 2022: (1)Ascorbic acid, (2) Carvedilol, (3 Cetirizine, (4) Docusate Sod/Senna, (5) Dutasteride, (6) Finasteride, (7) Levetiracetam, (8) Lorazepam, (9) Morphine Sulfate, (10) Multivitamin, (11) Rosuvastatin, (12) Sertraline, (13) Tamulosin, (14) Temazepam, (15) Tizanidine, (16) Vitamin B12 and (17) Xarelto.

Plan of correction

Agency Contracted Nurse is in the process of conducting a quarterly medication review to assess medication administrations for each resident. These reviews are to be done weekly and staffing shortage and requirement of Agency Contracted Nurse to conduct training of new hires has negatively impacted the reviews. However, nurse will complete a review of all resident MARs and will conduct refresher training/review with identified RMA as well as all RMAs to reinforce following medication administration protocols. Disciplinary action will be noted in staff record to enforce learning/compliance with any future non-compliances. Person Responsible: Agency Contracted Nurse and Administrator

July 20, 2022Inspection25 violations

Inspection dates

July 20, 2022 , July 28, 2022 and Aug. 15, 2022

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE

Comments

Type of inspection: Renewal An on-site unannounced renewal inspection was conducted on 7-20-22 by two inspectors. Ar. 05;20 a.m./dep 7:15 p.m. The facility census was 35. A tour of the facility was conducted, medication pass observed, breakfast and dinner meal observed, emergency preparedness items observed, water temperatures conducted, staff and resident records and interviews were also conducted. Potential violations were reviewed with staff throughout inspection process. A preliminary exit was conducted with the Activity director and the assistant to the administrator on 7-20-22. The Acknowledgement of Inspection form was sent via email. An exit meeting was conducted to review the inspection findings on 7-28-22 and 8-15-22. 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-70-A

Evidence

On 7-20-22, resident #2’s record documented in the nurse’s notes on 11-29-21 in early part of the morning resident sent to a local hospital by EMT following complaint of splitting headache, shaking and dizziness. Staff later documented on 11-29-21 at 4:37 p.m. resident was admitted for poly-pharmacy. The resident’s discharge summary from the local hospital noted resident was admitted on 11-29-21 and discharges on 12-1-21. Nurse’s noted dated 4-15-22 at 6:30 a.m. resident fell and was sent to Emergency Room following complaint of being dizzy and shortness of breath (SOB); recent admitted for septic pneumonia.
Resident #4’s nurse’s notes dated 5-7-22 at 7:30 a.m. documented resident and peer had a physical and verbal altercation in the smoking area. Staff separated the two residents from each other and administration notified.
Resident #5’s nurse’s notes dated 2-9-22 at 11:00 a.m. documented an unwitnessed fall, abrasion to forehead, sent out to local hospital via EMT. Nurse’s notes dated 2-9-22 at 4:45 p.m. documented resident had MRI completed at the hospital and returned with small bleed in the brain posterior.
On 7-20-22, inspectors reported to staff #2 and #3 incidents in residents? record not reported to the department.

Plan of correction

Administration acknowledge procedural failures due to change in staff designated to make reports. Procedural changes implemented whereby all incidents will be filtered through new assistant to the Administrator to ensure timely reports are made. All staff have been informed of requirement to report all activities defined as reportable incidents to the assistant to the administrator immediately. Assistant assumes responsibility with administrator to ensure all incidents are reported within 24 hours of occurrence. Person Responsible: Assistant to Administrator

22VAC40-73-120-A

Based on interview, the facility failed to ensure the orientation and training required in 22VAC40-73-120-B and C of the regulation occurred within the first seven working days of employment. Until this orientation and training is completed, the staff person may only assume job responsibilities if under the sight supervisions of a trained direct care staff person or administrator.

Evidence

On 7-20-22, staff #13 and #14 did not have a record and no documentation of orientation and training required per the regulation.
On 7-20-22, staff members #13 and #14 were not being supervised by a trained direct care staff person or administrator. The staff members were observed in the kitchen preparing breakfast and lunch meal and were not supervised by staff person or administrator. Staff #14 was also observed serving meals without staff or administrator supervision.
On 7-20-22, staff #1 and #2 acknowledged the aforementioned staff members had no record or documentation of orientation and training and supervision as required.

Plan of correction

Staff persons #13 and 14 were temporary employees to fill in during an emergency when cook staff departed without notice. A new cook has been hired effective 8/15/2022 and is completing orientation. The new staff speaks English and is an experienced cook. Staff persons 13 and 14 are no longer employed with the agency. In the future, only staff persons meeting eligibility criteria will be hired. Person Responsible: Administrator

22VAC40-73-160-E

Based on record reviewed and staff interviewed, the facility failed to ensure that the administrator who supervise medication aides shall be required annually to have four hours of training in medication administration specific to the facility population or a refresher course in medication administration offered by a Virginia Board of Nursing approved program.

Evidence

On 7-20-22, staff #1’s record did not have documentation of the medication refresher course as required for administrators who supervise medication aides.
On 7-20-22, staff #2 acknowledged staff #1 did not have documentation of training hours. On 7-28-22, staff #1 acknowledged not having required training hours.

Plan of correction

Administrator acknowledges that record did not have documentary evidence of the medication administration training although training had been taken. Administrator will file evidence of training in personnel record and will ensure annual training is documented on file upon completion of training in the future. Person Responsible: Administrator

22VAC40-73-210-B

Based on record reviewed and staff interviewed, the facility failed to ensure direct care staff attended at least 18 hours of training annually.

Evidence

On 7-20-22, staff #1’s record did not include documentation of annual training hours. The record did not include documentation of the required 4 hours of mental health and 2 hours of infection control training. Staff’s date of hire documented as January 2005.
Staff #?6’s record documented 13 of the required 18 hours of annual training and no documentation of the required 2 hours of infection control training. Staff’s date of hire documented as 7-21-09. 3 On 7-20-22 staff #2 acknowledged the aforementioned staff records did not have the required annual training hours
On 7 20 22 staff #2 acknowledged the aforementioned staff records did not have the required annual training hours.
On 7-28-22, staff #1 acknowledged staff not having required annual training hours and required areas of training.

Plan of correction

Documentation of the required trainings are being researched and documentation of trainings will be updated to files of staff #s 1, 2 and 6. To prevent future violations of this standard, Administrator is completing a complete review of all staff and implementing a training monitoring schedule to ensure all staff have required training by due dates. The trainings will be reviewed quarterly to ensure all staff trainings are kept up to date. Nurse will ensure all trainings are conducted as required. Assistant administrator will ensure training is properly documented and Administrator will ensure additional training resources are made available when required. Person Responsible: Administrator, Nurse and Assistant Administrator

22VAC40-73-250-A

Based on staff interviewed, the facility failed to ensure a record shall be established for each staff person and include all required personal and social data shall be maintained on staff.

Evidence

On 7-20-22, a request was made for the records for staff #13 and #14.
Staff #1 acknowledged the facility did not have records for the staff members.

Plan of correction

Facility hired employees #13 and 14 during a staffing emergency due to their cooking skills when staff departed without notice. Personnel records documentation was initiated, but not completed. Both employees are no longer employed by agency as permanent employee replacements have been hired. To prevent future violations of this standard, Administrator will ensure all employees hired to work in facility complete required documentation prior to initiating employment services. Assistant to administrator will be responsible for supplying and collecting documentation and keeping accurate files. Nurse will ensure training of all staff hired. Administrator will conduct a review of all employee files to ensure required documentation is on file. Person Responsible: Administrator, Assistant to Administrator and Agency Nurse

22VAC40-73-250-C

Based on staff interviewed, the facility failed to ensure a record shall be established for each staff person and include all required personal and social data shall be maintained on staff.

Evidence

On 7-20-22, a request was made for the records for staff #13 and #14.
Staff #1 acknowledged the facility did not have records for the staff members

Plan of correction

Administrator is locating documentation for employees #6 and 7, and will ensure filing of required documentation, To prevent future violations of this standard, Administrator will ensure all employees hired to work in facility complete required documentation prior to initiating employment services. Assistant to administrator will be responsible for supplying and collecting documentation and keeping accurate files. Nurse will ensure training of all staff hired. Administrator will conduct a review of all employee files to ensure required documentation is on file. Person Responsible: Administrator, Assistant to Administrator and Agency Nurse.

22VAC40-73-250-D

Based on record reviewed and staff interviewed, the facility failed to ensure a staff person within seven days prior to the first day of work at the facility submitted the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
On 7-20-22, staff #5’s record did not include an updated TB. The record included a TB dated 11-29-17. Staff’s date of hire documented as 12-16-17.
Staff #7’s TB form in the record was dated 6-1-22 was incomplete and did not document the absence of TB in a communicable form. Staff’s date of hire documented as 6-1-22. Staff #7 has been documented on the schedule to consistently be working on the floor with residents.
On 7-28-22, staff #1 acknowledged the aforementioned staff’s TB was not within the regulation requirement.

Plan of correction

22VAC40-73-290-A

Based on document observed and staff interviewed, the facility failed to ensure the written work schedule includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time.

Evidence

On 7-20-22, the C.N.A. and Direct Care Staff, Dietary, and RMA staff’s schedule for July 3 to August 2022 did not indicate whomever is in charge at any given time. The schedules also noted only the first name of the staff member. 2.On 7-20-22, staff #2 acknowledged, the schedule did not include all required information.

Plan of correction

Written work schedule has been updated. To prevent future violations of this standard, the scheduler will ensure each written work schedule includes the names and job classifications of all staff working each shift along with an indication of who is in charge is included. The charge staff will be required to check the schedule at initiation of shift to ensure it is accurate and make corrections as required. This activity will be monitored daily by Assistant to administrator and Nurse and documented. This issue will be discussed during weekly staff meetings to ensure compliance. Person Responsible: Administrator, Assistant to Administrator Agency Nurse, Charge RMA

22VAC40-73-290-B

Based on observation and staff interviewed, the facility failed to ensure the posting of the name of current on-site person in charge was conducted.

Evidence

On 7-20-22, the name of the staff person listed was the individual from the previous 6:30- a.m. shift on 7-19-22.
Staff #4 acknowledged the staff person in charge posting was not updated.

Plan of correction

22VAC40-73-310-H

Based on record review and staff interviewed, the facility failed to ensure in accordance with 63-2-1805 D of the Code of Virginia, the assisted living facility shall not admit or retain individuals with prohibitive conditions.

Evidence

On 7-20-22, resident #3’s treatment plan for psychotropic medication, Seroquel was incomplete.
Resident #2’s “Documentation of Physician’s Order for Psychotropic Medication” documented “N/A”. The resident’s medication administration record (MAR) for July 2022 documented resident was administered the following psychotropic medications: Lorazepam, Temazepam, Zoloft and Trazadone.
On 7-28-22, CS #1, acknowledged treatment plan was not completed as required for the aforementioned residents.

Plan of correction

Agency Contracted Nurse is reviewing resident #3’s treatment plan for update. Treatment will be appropriately updated after consultation with resident’s treatment practitioner. To prevent future violations of this standard, the administrator, assistant to the administrator, Agency Contracted Nurse, Activities Coordinator and RMAs are reviewing 100% of all residents records to identify those requiring updated treatment plans. Review will be documented and plans requiring update will be accomplished. In addition, Administrator, Assistant to Administrator, Agency Contracted Nurse, Activities Coordinator and RMAs will meet weekly to review residents requiring updated treatment plans. Weekly reviews will be documented. Person Responsible: Administrator, Assistant to Administrator, Agency Contracted Nurse, Activities Coordinator and RMAs

22VAC40-73-320-B

Evidence

On 7-20-22, resident #2’s TB was dated 6-8-21, resident’s date of admit documented as 7-13-17.
Resident #5’s TB was dated 6-8-21, resident’s date of admit documented as 10-12-17.
Resident #6’s TB was dated 6-8-21, resident’s date of admit documented as 10-20-20.
On 7-20-22, staff #2 acknowledged the aforementioned TB’s were not completed annually as required.
On 7-28-22, staff #1 and CS#1 acknowledged the TB forms were not completed as required.

Plan of correction

The assistant to the Administrator and agency Contracted Nurse are addressing TB Risk Assessments for residents #2, 5 and 6. To prevent future violations of this standard, the Administrator, Assistant to the Administrator and Agency Contracted Nurse and an assistant are reviewing 100% of resident files to identify those in need of annual risk assessment. In addition, agency contracted nurse and assistant to administrator have been informed to ensure an updated risk assessment is to occur following any falls. Falls and risk assessments will be reviewed monthly to ensure any fall is accompanied by an updated assessment. Assistant to administrator is to be informed of any fall to initiate update of risk assessment by agency contracted nurse. Person Responsible: Administrator, Assistant to Administrator, Agency Contracted Nurse

22VAC40-73-325-B

Based on record reviewed and staff interviewed, the facility failed to ensure the fall risk rating was reviewed and updated after each fall.

Evidence

On 7-20-22, resident #2’s nurse’s notes dated 4-15-22 (6:30 a.m.), documented resident fell and was sent to the hospital. The record did not include an updated fall risk rating. The risk rating document in record was dated 11-15-21.
Resident #2’s nurse’s notes dated 3-15-22 (6:50 a.m.), documented resident stated to staff, ?slipped while taking a shower?. The risk rating document in the record was dated 1-2-22.
Resident #5’s nurse’s notes dated 2-9-22 (11:00 a.m.) an unwitnessed fall and sent to ER. On 2-17-22 (6 a.m.) nurse’s notes documented resident fell. The fall risk rating document in record was dated 4-16-21.
On 7-28-22, staff #1 and CS1 acknowledged the fall risk rating was not updated following the aforementioned residents? fall.

Plan of correction

Agency Contracted Nurse, Activities Coordinator and Assistant to Administrator are reviewing records of residents #2, 5, and 6 to review falls and need for updated risk rating. Agency Contracted Nurse will update risk assessment on residents requiring update. To prevent future violations of this standard, staff will notify assistant to administrator of all falls immediately. Assistant to administrator will submit incident reports to DSS Licensing and meet with agency Contracted Nurse to have updated risk rating completed. Agency Contracted Nurse will complete updated risk rating with 72 hours of fall. All falls will be reviewed by Administrator, Assistant to Administrator, Agency Contracted Nurse, Activities Coordinator and RMAs weekly. Weekly reviews will be documented. Person Responsible: Administrator, Assistant to Administrator, Agency Contracted Nurse, Activities Coordinator and RMAs

22VAC40-73-440-D

Based on record reviewed and staff interviewed, the facility failed to ensure for a private pay individual, the Uniformed Assessment Instrument (UAI) is completed as required 22VAC30-110.

Evidence

On 7-20-22, resident #2’s UAI dated 11-15-21 was not signed by the designee or administrator.
Resident #6’s UAI dated 4-10-21 was not signed by the designee or administrator.
On 7-28-22, staff #1 and CS1 acknowledged the aforementioned UAI was not signed and dated as required.

Plan of correction

Nurse and Assistant to Administrator are addressing update of UAI for residents #2 and 6. To prevent future violations of this standard, the Administrator, Assistant to Administrator and Agency Contracted Nurse are reviewing 100% of all resident records to assess need for updated UAI. A monthly log of UAI updates needed will be maintained by Assistant to Administrator and Agency Contracted Nurse to ensure UAIs are updated timely. In addition, the facility is training two additional staff to complete UAIs to assist nurse in meeting update deadlines. Person Responsible: Administrator, Assistant to Administrator and Agency Contracted Nurse

22VAC40-73-440-H

Evidence

On 7-20-22, resident #6’s UAI was dated 10-30-20 and 4-10-21. The resident’s date of admit was documented 10-30-
On 7-29-22, staff #1 and CS#1 acknowledged the aforementioned resident’s UAI was not completed annually as required.

Plan of correction

Nurse and Assistant to Administrator are addressing update of UAI for residents #6. To prevent future violations of this standard, the Administrator, Assistant to Administrator and Agency Contracted Nurse are reviewing 100% of all resident records to assess need for updated UAI. A monthly log of UAI updates needed will be maintained by Assistant to Administrator and Agency Contracted Nurse to ensure UAIs are updated timely. In addition, the facility is training two additional staff to complete UAIs to assist nurse in meeting update deadlines. Person Responsible: Administrator, Assistant to Administrator and Agency Contracted Nurse, Activities Coordinator and RMA

22VAC40-73-450-F

Plan of correction

Agency Contracted Nurse is reviewing resident #s 2 treatment plan for update. Treatment plan will be appropriately updated after consultation with resident’s treatment practitioner. To prevent future violations of this standard, the administrator, assistant to the administrator, Agency Contracted Nurse, Activities Coordinator and RMAs are reviewing 100% of all resident’s records to identify those requiring updated treatment plans. Review will be documented and plans requiring update will be accomplished. Any resident who discharges from or leaves the facility for an extended period of time will have an updated treatment plan completed upon reentry. In addition, Administrator, Assistant to Administrator, Agency Contracted Nurse, Activities Coordinator and RMAs will meet weekly to review residents requiring updated treatment plans. Agency Contracted Nurse will ensure updated plans are accomplished. Weekly reviews will be documented. Person Responsible: Administrator, Assistant to Administrator, Agency Contracted Nurse, Activities Coordinator and RMAs

22VAC40-73-550-G

Based on record reviewed and staff interviewed, the facility failed to ensure the rights and responsibilities of residents in assisted living facility shall be reviewed annually with each resident or his legal representative or responsible individual and each staff person.

Evidence

of this review shall include the date of the review and shall be filed in the resident’s or staff person’s record. Evidence:
On 7-20-22, staff #1 did not have documentation of annual rights and responsibilities (RR) reviewed; document in record last dated 10-1-19. Staff’s date of hire documented 1- 2005.
Staff #5’s record did not have documentation of annual RR reviewed. Staff’s date of hire documented as 12-16-17.
Staff #6’s record did not have documentation of annual RR reviewed. Staff’s date of hire documented as 7-21-09.
Residents #1, #4, #5, #6 and #7’s rights and responsibilities was last signed and dated 5-14-21.
Resident #2’s record did not have documentation of rights and responsibilities, resident’s date of admit documented as 7-13-17.

Plan of correction

Assistant administrator has completed review of resident’s rights and responsibilities with staff #s 1,5, and 6 as well as with residents #1,4,5,6 and 7. To prevent future violations of this standard the administrator and assistant are completing a 100% review of all residents files to ensure rights reviews are up to date. In addition, chart audits will be completed monthly using a chart audit form to ensure required actions are completed timely in the future to include rights reviews, UAI and ISP updates, medication renewals, and other required activities. Findings from these reviews will be documented, completed and reviewed with management staff monthly. Person Responsible: Administrator, Assistant to Administrator, Agency Nurse, Scheduler

22VAC40-73-580-A

Evidence

On 7-20-22, the date of the facility’s last health inspection was dated 2-28-21.
On 7-20-22, staff #2 acknowledged the facility did not have an annual health inspection.

Plan of correction

Facility has obtained a current Department of Health Inspection of the facility. Facility had requested inspection prior to unannounced review on 7/20/2022, but Department of Health had not completed the inspection. Inspection was completed on August 17, 2022. To prevent future violations of this standard, assistant to the Administrator will ensure facility inspection is requested within 60 days of expiration of current inspection with a follow-up request within 30 days expiration of the inspection. Person Responsible: Administrator and Assistant to the Administrator

22VAC40-73-640-A

Based on observation, record reviewed, document reviewed, and staff interviewed, the facility failed to implement its medication management plan to ensure a resident’s prescription medication was filled and refilled in a timely manner to avoid missed dosages.

Evidence

On 7-20-22 during the medication pass observation with staff #5, resident #2’s Finasteride was not available to administer. The July 2022 medication administration record (MAR) documented medication is prescribed daily at 8:00 a.m. The medication was not available, “Awaiting on pharmacy to supply” on 7-1-22; 7-2-22; 7-4-22; 7-5-22; 7-7-22; 7-9-22; 7-10-22 and 7-20-22.
Staff #5 acknowledged resident’s medication was not available to administer at the prescribed time.

Plan of correction

Resident #2 desired to change pharmacies due to cost of medications. The new pharmacy required medications to be mailed in, thereby requiring additional time for receipt of the medication. Pharmacy change did not occur in time to obtain medication from new pharmacy and resident refused to obtain medication from currently used pharmacy due to cost. Facility updating medication ordering protocol to have RMA reorder medications 10 days prior to depletion of medications to give pharmacy opportunity to have medications available in time to prevent any future missed medications. Agency contracted nurse will review medications weekly to ensure medications are timely ordered. Person Responsible: Agency Contracted Nurse and RMA

22VAC40-73-680-B

Based on observation and staff interview, the facility failed to ensure medication shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.

Evidence

On 7-20-22 during a check of the Assisted Living unit medication cart in the medication room with staff #5, when the inspector opened the top drawer of the medication cart, an unlabeled opened cup of rice pudding with medication was observed in the top drawer.
Staff #4 acknowledged the medication in the rice pudding cup was Depakote and Motrin for resident #8.

Plan of correction

RMA had poured medications into applesauce for administration but had not administered at time of inspector’s entrance. RMA fully aware of requirement to timely administer medications. Agency Contracted Nurse will conduct refresher training/review with identified RMA as well as all RMAs to reinforce following medication administration protocols. Disciplinary action will be noted in staff record to enforce learning/compliance. Person Responsible: Agency Contracted Nurse and Administrator

22VAC40-73-720-A

Based on record reviewed and staff interviewed, the facility failed to ensure the written order for a Do Not Resuscitate (DNR) was accurately completed as required.

Evidence

de ce:
On 7-20-22, resident #5’s record included a signed and dated Do Not Resuscitate (DNR) order dated 2-26-21. The document did not indicate if the resident was capable or not capable of making informed decision. The document did not indicate if the individual had executed an advanced directive directing with-holding life- long procedures.
The resident’s individualized service plan (ISP) dated 9-28-21 documented the resident’s code status as DNR.

Plan of correction

Agency Contracted Nurse is addressing DNR order for resident #5. To prevent future violations of this standard, agency contracted nurse, assistant administrator and administrator will review all DNR orders within 24 hours of being issued to ensure accurate completion. Documentation of review will be completed via progress note or other documentation included in file. DNR Orders will be review quarterly to ensure they are accurately applied for, completed, maintained and that staff are trained on them upon being issued. Person Responsible: Administrator, Agency Contracted Nurse and Assistant to Administrator

22VAC40-73-870-A

Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair and kept clean and free of rubbish.

Evidence

On 7-20-22 during a check of the water temperature in room and call bell system in room #43, the bathroom door did not have a door knob. The washer on the faucet at the face sink was in need of repair. When the hot water was turned on it sprayed water in multiple direction causing the inspectors clothes to get wet.
Staff #4 responded to the call bell and acknowledged the water issue and bathroom door knob missing in room #43.

Plan of correction

The door knob on room #43 and the washer on the faucet have been repaired. To prevent future violations of this standard, facility maintenance repairs will be requested immediately upon being notified of the need. Facility inspections will be conducted weekly and repair needs documented. Documentation will reflect repair needs and dates of completion of the repairs. Repairs potentially affecting the health and safety of the residents will be addressed immediately or resident moved to a safe place until repairs are made. Person Responsible: Administrator

22VAC40-73-960-B

Based on observation and staff interviewed, the facility failed to ensure fire and emergency evacuation drawing posted on the walls in the facility did not include the location on the telephones in the facility.

Evidence

On 7-20-22 during a tour of the facility with staff #4 and #5, the evacuation posting across from room #54 and to the right of the current activity room #38 did not include the location of the telephone(s) in the facility.
The aforementioned staff acknowledged the fire and emergency evacuation posting did not include the location of telephone(s).

Plan of correction

Evacuation drawings across from rooms #54 and to the right of room #38 have been updated to include the location of telephones. To prevent future violations of this standard all evacuation drawings will include the location of telephones. The assistant to the administrator or designee will include review of evacuation drawings on the monthly inspection checklist. Person Responsible: Assistant to Administrator

22VAC40-73-980-H

Based on observation and staff interviewed, the facility failed to ensure the availability of a 96-hour supply of emergency food and drinking water. At least 48 hours of the supply must be on site at any given time, of which the facility’s rotating stock may be used.

Evidence

On 7-20-22 during a check of the emergency food, there were 3, number 10 cans of baked beans, 1 number 10 can of black-eyed peas, 6 canisters of 42 ounces of Oatmeal (30 servings per container); 4 (56 ounces of berry flavored dry cereal- 42 servings a bag); 1 bag of Tootie/Fruitie cereal (32 servings a bag) and 2 bags of Frosted Flakes (41 servings per bag). There was also 1- tub of peanut butter (71 servings) and 3 jars of peanut butter (57 servings each) and 25 cans of tuna (5 ounces each). The facility is currently licensed for 85 residents. The census on 7-20-22 was 35.
Staff #1 acknowledged the facility did not have at least 48 hours of supply on-site.

Plan of correction

The 96 hour emergency food supply has been secured and stored at the facility. The 96-hour supply will be maintained strictly for emergencies and be maintained at all times. Food supply will be reviewed monthly and evidence of availability documented. Person Responsible: Administrator and Food Service Supervisor

22VAC40-80-120-E-2

Based on observation and staff interviewed, the facility failed to ensure the findings of the most recent inspection of the facility was posted in the facility.

Evidence

On 7-20-22 during a tour of the facility, staff #3 was asked where the most recent inspection was posted. Staff looked near the front desk where the sign in sheet and current license was posted, but the recent inspection was not available.
On 7-20-22 staff #2 and #3 acknowledged the current inspection was not posted in the facility when the inspectors arrived. ilit h ill b

Plan of correction

Findings of the most recent facility has been posted and in the future inspections will be posted immediately upon receipt. The administrator and Assistant to the Administrator will be responsible for ensuring the most recent inspection is posted upon receipt. Person Responsible: Assistant to Administrator

22VAC40-90-40-B

Based on the employee 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 employee.

Evidence

On 7-20-22, staff # 12 and #13 did not have documentation of a sworn disclosure and criminal history record. There was no date of hire information available for staff #13 and #14.
Staff # 7’s criminal history report was dated 7-14-22. Staff’s date hire was documented as 6-1-22.
Staff #9’s criminal history report was dated 7-14-22. Staff’s date of hire was documented as 6-7-22.
Staff #11’s criminal history report was dated 6-14-22. Staff’s date of hire was documented as 5-25-22.
On 7-20-22 Staff #2 acknowledged the aforementioned staffs criminal record report was not obtained within the required 30 days of hire.

Plan of correction

Employee #s 7, 9 and 11 had criminal history request documentation completed upon hire, however access to the system to request the checks delayed submission of the requests due to departure of previous staff who processed requests. The assistant to the Administrator currently ensures background check documentation is requested immediately upon hire and submits requests. Employees #13 and 14 were hired to address a crisis and there was a delay in obtaining documentation from them. Employees #13 and 14 are no longer employed by the agency, however in the future documentation to secure background checks will be obtained from all employees immediately upon hire and prior to initiating providing services. Person Responsible: Assistant to Administrator

April 29, 2022Complaint survey1 violation

Inspection dates

April 29, 2022 and May 20, 2022

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES

Comments

Type of inspection: Complaint Complaint onsite inspection conducted on 4-29-22 (Ar 1:00 pm./dep 2:45 p.m.) The Acknowledgement of Inspection form was sent via electronic format. A complaint was received by VDSS Division of Licensing on 4-29-22 regarding allegations in the administration and administrative services, resident personal spending funds. The census was 30. There was one resident record reviewed. Interviews conducted with one resident. Interviews conducted with two staff members. Record for resident reviewed. Business files and financial documents reviewed for the resident.: An exit meeting will be conducted to review the inspection findings. An exit was conducted via virtual meeting on 6-10-22 with the Administrator, assistant to administrator and consultant The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint 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 Willie Barnes Licensing Inspector at 757-439-6815 or by email willie.barnes@dss.virginia.gov

Violations

22VAC40-73-80

Based on record reviewed and staff interviews, the facility failed to ensure it maintained a written accounting of money received and disbursed by the licensee, facility administrator, or staff person that shows a current balance. The written accounting of the funds shall be made available to the resident at least quarterly and upon request, and a copy shall also be placed in the resident’s record. The resident’s funds shall be made available to the resident upon request.

Evidence

On 4-29-22 during a complaint inspection regarding a resident not receiving personal funds since December 2021, the resident stated requesting funds from the administrator/licensee but did not receive funds. Resident #1 stated during interview not receiving personal fund in the amount of $80, the amount always given by the previous business office manager. According to resident this was the amount that was dispersed to resident since admission September 2018.
The resident’s record included notice statements from a payee source (Auxiliary Grant letters dated 5-30-20, 11-12-20, 5-6-21 and 11-17-21) documenting the resident’s monthly personal fund amount was $82.
The resident’s record did not include documentation of $82 being dispersed to the resident.
Staff #1 and #2 were shown notices in the resident’s record from the payee source from the time of admission until January 2022, noting the resident was to receive $82 personal spending.
During interview with staff #1, staff stated an account was established for resident #1 to receive personal funds using a debit card. The resident had not yet receive personal funds.
Staff #1 acknowledged the resident’s record did not include documentation of $82 monthly payments. Staff also acknowledged resident had not been given monthly personal fund payments since December 2021.

Plan of correction

Not published by VDSS.

March 28, 2022Complaint survey4 violations

Inspection dates

March 28, 2022 and March 29, 2022

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS

Comments

Licensing inspector conducted an on-site complaint inspection on 3-28-22 and 3-29-22 (ar 07:30 a.m/dep 6:00 pm on day 1 of inspection. The Acknowledgement of Inspection form was sent via electronic email for both days of inspection. A complaint was received by VDSS Division of Licensing on 3-20-22 regarding allegations in the resident food and meal. There were 40 residents present on 3-28-22, day 1 of the complaint inspection. A tour of the dining area, kitchen and food storage areas were conducted. Resident interviews were conducted, residents? preference to speak if names would not be provided. There were six staff member interviews conducted Observation of the breakfast, lunch and dinner meals were conducted on day 1, 3-28-22. Facility toiletries were observed as this was a concern during interview with a resident. An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint 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 Willie Barnes Licensing Inspector at 757-439-6815 or by email willie.barnes@dss.virginia.gov

Violations

22VAC40-73-610-B

Based on observation and staff and resident interviews, the facility failed to ensure the menus and snacks for the current b tit ti dditi week included substitutions or additions to the posted menu.

Evidence

On 3-28-22, the dinner menu for 3-27-22 documented lemon herb linguine, mixed vegetables, garlic bread and soup or salad. Interview with residents and staff #3, the residents? were served bar-b-que ribs, yams, collard greens, and corn muffins. This meal was provided by staff #3 from personal supply. Menu did not reflect this change.
On 3-28-22, the breakfast menu documented biscuits and gravy, scrambled eggs, fresh fruit, “ cup of oatmeal or ” cup dry cereal. Based on observation, no eggs or fresh fruit was served. The menu did not reflect the changes, first seating received bacon and second seating served sausage patties because there was not enough of either to serve the census of 40. No eggs were served at breakfast, this change was not on the breakfast menu posted.
The menu for lunch on 3-28-22 noted turkey and Swiss sandwich, onion rings and mixed fruit. The inspector observed turkey and American cheese sandwich, fruit cocktail, potato chips and ? sliced pickle and tostados chips served at second seating .These changes were not documented on the lunch menu.
Dinner menu listed the following items: BBQ pork loin, mashed potatoes, collard greens, soup or salad, dessert, coffee- tea-lemonade. The following was observed served: BBQ pork loin, baked beans, strawberry cake with vanilla frosting, bread sticks, coffee. The changes were not documented on the lunch menu.

Plan of correction

Not published by VDSS.

22VAC40-73-610-C

Based on observation, document reviewed and staff interviewed, the facility failed to ensure the daily menu, including snacks, for each resident met the current guidelines of the U.S. Department of Agriculture’s food guidance system or the dietary allowances of the Food and Nutritional Board of the National Academy of Sciences, taking into consideration the age, sex and activity of the resident.

Evidence

On 3-28-22 during a complaint inspection regarding the facility not having food, the morning meal was observed. The cooking staff did not have sufficient amount of food for all residents. The facility census on was 40. The menu listed the following items for breakfast: biscuit and gravy, scrambled eggs, fresh fruit, 1/2 cup oatmeal or ? cup dry cereal, coffee- milk-juice. The first seaters were served: bacon, some received oatmeal and some received biscuit and gravy. The second seaters were served biscuit and gravy, sausage patties and banana. There was not enough biscuit and gravy for everyone during the second seating. There was only enough bananas for the second seaters. According to dietary staff, this has been the situation for about month. There is not always enough food for everyone to receive what is on the menu or when the residents request seconds. This was also confirmed during interviews with residents.
The eggs in the refrigerator could not be served because it was needed for the egg and cheese omelet for Tuesday, 3- 29-22’s meals; egg and cheese omelet and egg salad sandwich for lunch.
A check of the food supply in the kitchen/pantry refrigerators and storage area determined there was a lack of food within the facility for 40 residents to receive a nutritious well-balanced meal (breakfast, lunch and dinner) and provide lunch meals for the residents who took lunch to their day program.
The residents were not provided seconds were asked due to the insufficient amount and availability of items served.
Interviews with residents and staff stated, a staff member personally brought food to the facility and prepared it for the residents for Sunday, 3-27-22’s dinner meal. According to interviews and information on the menu, the residents stated the facility have not had enough food since a staff member left about a month ago.
The facility have a monthly menu posted, however, the items on the menu are not available and what is posted is not being provided to the residents during mealtimes. A well- balanced meal as required was not observed served on 3-28-22.

Plan of correction

Not published by VDSS.

22VAC40-73-610-E

Based on interviews, the facility failed to ensure a copy of a diet manual containing acceptable practices and standards of nutrition was kept current and readily available to personnel responsible for food preparation.

Evidence

On 3-28-22, the lead cook for the morning was asked if there was a copy of the facility’s diet manual. The staff was not able to locate the required diet manual.
Staff was asked what reference was used to make substitutions when an item on the menu was not available or preparation for items for residents who were diabetic. Staff stated using whatever was on hand or not giving a resident an item if their diet stated they could not have what was being served.

Plan of correction

Not published by VDSS.

22VAC40-73-980-G

Based on observation and staff interviewed, the facility failed to ensure the availability of a 96-hour of supply of emergency food and drinking water. At least 48 hours of the supply must be on site at any given time, of which the facility’s rotating stock may be used.

Evidence

On 3-28-22 during a complaint regarding facility’s lack of food, staff was asked why not use the emergency food supply to address the food limitation in the pantry. Staff stated there was no real emergency food. A check of the facility food storage determined there was limited emergency food available. The pantry contained 2-#10 cans of yams, 6- #10 cans of corn, 4-#10 cans of green beans, 1-#10 can of black eyed peas, 4 #-10 cans of beets, 3- 15 ounce cans of chicken (66 5 4 (42 soup and 3 cans of tuna (66.5 oz.). There was also 4 (42 ounce) container of oatmeal, 1- 30 ounce container of creamy peanut butter and 1- 4 pound container of peanut butter, 9 loaves of bread, and 2 boxes - 17.6 ounces of corn flakes. There also other condiment items available (ketchup, mustard, salad dressings,) 2.On 3-29-2 2, staff #1 acknowledged the facility did not have 48 hour of emergency food stored on hand.

Plan of correction

Not published by VDSS.

March 28, 2022Inspection9 violations

Inspection dates

March 28, 2022 and March 29, 2022

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report

Comments

An unannounced monitoring inspection was conducted on 3-28-22 and 3-29-22. The facility census was 40. A tour of the facility was conducted, a medication pass observation was conducted, review of staff and residents records, interviews with staff and residents, breakfast and lunch meal observed, emergency preparedness information observed. A review of violations were reviewed with staff throughout the inspection process. An exit was conducted on 3-29-22 with the assistant to the Administrator and nurse consultant. The acknowledgement form was sent via email to the Administrator. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. POC due 4-22-22 If you have any questions, contact your licensing inspector at (757) 439-6815.

Violations

22VAC40-73-40-B

Based on observation and staff interviewed, the facility failed to ensure that the current license was posted in the facility in a place conspicuous to the residents and the public.

Evidence

On 3-28-22, the licensed posted in the facility was an annual license which expired 2-28-22. The current license is a Provisional license and expires 8-28-22.
Staff #1 and #2 acknowledged during the course of the inspection process the facility did not have the current license posted.

Plan of correction

Not published by VDSS.

22VAC40-73-210-B

Based on record reviewed and staff interviewed, the facility failed to ensure direct care staff who are certified nurse aides shall attend at least 12 hours of annual training.

Evidence

Staff #3’s record did not include documentation of 12 hours of annual training. Staff’s record included 9 hours of training (5 hours infection control and 4 hours of medication refreshers). Staff’s date of hire document as 8-13-07. ect Sta ?s date o e docu
Staff #2 and CS-1 acknowledged the aforementioned staff’s record did not have documentation of the required 12 hours of annual training.

Plan of correction

Not published by VDSS.

22VAC40-73-290-A

The facility failed to ensure it maintained a written work schedule for all staff that included the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time.

Evidence

On 3-28-22 a request was made for the staff schedule for each department and to highlight any new staff since the facility’s last inspection per the “What your inspector needs from you today”, form.
The facility did not have schedules for the following department staff, administrator and assistant to administrator, housekeeping, activity, transportation and dietary.
The direct care staff schedule did not include the names of agency staff documented on the schedule, it simply stated “Agency”.
Staff #1 and #2 acknowledged during course of inspection process, the facility did not have schedules for the aforementioned departments.

Plan of correction

Not published by VDSS.

22VAC40-73-310-H

Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions or care needs for one of six residents.

Evidence

Resident #2’s March 2022 medication administration record (MAR) documented resident prescribed Trazadone, the physician order summary (POS) dated 3-15-22 also documented resident’s Trazadone. The resident’s record did not include a signed and dated psychotropic treatment plan. Resident also prescribed Risperidone, treatment plan did not include a date the plan was signed.
Staff #2 and CS-1 acknowledged during exit meeting the aforementioned resident’s record did not contain a treatment plan for prescribed psychotropic medication.

Plan of correction

Not published by VDSS.

22VAC40-73-450-C

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for four of six residents.

Evidence

Resident #1’s uniformed assessment instrument (UAI) dated 7-2-21 documented bathing need as mechanical help/physical assistance. The individualized service plan (ISP) dated 7-2-21 documented mechanical help and Supervision (grab-bar and cues/ reminders). Wheeling need assessed as not performed; the ISP did not include this assessed need.
Resident #3’s UAI dated 4-7-21 documented wheeling need as not performed. This need was not included on the ISP dated 4-7-21.
Resident #4’s UAI dated 11-19-21 documented wheeling need as not performed. This need was not included on the ISP dated 11-30-21.
Resident #6’s UAI dated 6-28-21 documented bathing need as mechanical help/physical assistance. The ISP dated 3- 1-22 mechanical help/ supervision (cueing needed). Wheeling need documented as not performed. This need was not included on the ISP dated 3-1-22.
Staff #2 and CS-1 acknowledged during the exit meeting the aforementioned residents? records did not include all assessed needs.

Plan of correction

Not published by VDSS.

22VAC40-73-640-A

Based on observation and staff interviewed, the facility failed to ensure that methods to prevent the use of outdated, damaged, or contaminated medications was conducted.

Evidence

On 2-29-22, during a check of the medication cart with staff #4, resident #1’s Permethrin cream had an expiration date of 3-4-22.
Staff #4 and CS-1 acknowledged the aforementioned medication should not have been on the cart due to it being expired.

Plan of correction

Not published by VDSS.

22VAC40-73-660-A

Based on observation and staff interviewed, the facility failed to ensure medications storage area was locked.

Evidence

On 2-28-22, staff #---- was administering eye-drops to a resident at the window. The inspector walked into the medication room and noticed the medication cart located on the right wall of the medication room was not locked. The staff was at the window behind the wall administering the eye-drop and talking with CS-2.
On 2-29-22, during a check of the medication cart with staff #3, it was observed that the refrigerated medications were not stored in a locked storage room. The refrigerator with residents? medications were stored in the staff breakroom down the hallway from the medication room. This room is not locked and the door was open.
Staff #3 and CS-1 acknowledged during the course of the inspection that medication cart was not locked and refrigerated medications were not stored in a locked room.

Plan of correction

Not published by VDSS.

22VAC40-73-680-B

Based on observation and staff interviewed, the facility failed to ensure medication shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.

Evidence

On 2-28-22 at approximately 5:05 p.m., the licensing inspector was in the medication room and noticed the medication cart was unlocked. Staff #8 finished administering a resident’s eye-drops and came back to the medication cart. Staff #8 opened the top portion of the medication cart and a container with pre-poured medications was observed. Staff stated it was resident #7’s Clozaril that was crushed and mixed for administration. Other medications for resident #7 that were observed pre-poured included Klonopin, Fibercon and Ibuprofen.
Staff #8 acknowledged preparing the medications beforehand to administer later to resident #7 on 2-28-22.

Plan of correction

Not published by VDSS.

22VAC40-73-690-G

Based on document reviewed and staff interviewed, the facility failed to ensure it took action in response to the recommendation noted in the pharmacy review and documented the information in the resident’s record.

Evidence

On 2-29-22, the pharmacy review dated 2-15-22 document recommendations for the resident #1, #2, #3 and #5. The recommendation actions taken were not completed.
CS-1 acknowledged no action was taken of the pharmacy’s recommendation for the aforementioned resident’s medications.

Plan of correction

Not published by VDSS.

December 15, 2021Complaint survey1 violation

Inspection dates

Dec. 15, 2021 , Dec. 22, 2021 , Feb. 2, 2022 , Feb. 8, 2022 and Feb. 17, 2022

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES

Comments

An unannounced complaint inspection was conducted on 12-15-21 regarding an allegation of residents not receiving personal fund resources from stimulus income. The evidence gathered during the investigation supported the non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendars of receipt. If you have any questions, contact the licensing inspector at (757) 439-6815. Plan of correction is due by 3-1-2022

Violations

22VAC40-73-80

Based on documents reviewed, staff, resident and collateral interviews, the facility failed to ensure it maintain accounting of money received and disbursed by the facility that shows a current balance. The written accounting of the funds shall be made available to the resident at least quarterly and upon request, and a copy shall be placed in the resident’s record.

Evidence

On 12-15-21 during interview with resident #1 and #3, it was reported that staff #1 had a debit card for the residents. Residents stated not knowing how much money on card.
On 12-15-21 during interview with staff #1, staff provided two debit cards to the inspectors and stated resident’s need for a pin number. Staff also stated not knowing how to access the account when asked the amount of funds in the account and on the debit cards for resident #1 and #3. Staff stated staff #1 was the only one with access to the account that contained the resources for the resident #1 and #3’s debit account.
On 12-15-21, documents of residents account information was requested and documents were received on 12-22-21. Documents received did not include resident’s personal fund accounting information requested. Resident’s delegation statement for the facility to assist the resident in management of personal funds was received.
On 2-8-22- request for personal fund statements requested again from staff #1 and email sent again with specific requested documents.
Staff #2 faxed documents to office on 2-11-22. Documents reviewed did not provide detailed account of resident #1 and #3’s personal spending fund, it did not provide documentation of resident’s money deposited, dispersed and remaining balance. Resident #1 and #3 signed delegation statement documented the facility would provide personal spending check monthly and resident would sign monthly for each check.
On 2-17-22 during exit meeting with staff #1, staff acknowledged the accounting statement provided to resident #1 and #3 regarding personal spending funds did not meet the requirements of the personal delegation statement and did not meet the requirements of the regulations.

Plan of correction

Colonial Manor has changed the system of collecting and distributing funds under the Representative payee as follows:

December 15, 2021Inspection10 violations

Inspection dates

Dec. 15, 2021

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS63.2 Protection of adults and reporting63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report

Comments

An unannounced renewal inspection was conducted by two inspectors on 12-15-21 (ar 6:35 am/dep 5:30 p) The census was 41. A medication pass was observed, a tour of the facility conducted, staff and resident interviews conducted, the breakfast, lunch and dinner meal was observed. A review of resident and staff records were also reviewed, consultant reports, emergency preparedness documents and first aid kits. The administrator was not present. An initial exit was conducted with the assistant to the administrator and the nurse consultant. The acknowledgement form was completed and sent on 12-22-21 following a second exit meeting with the Assistant to the Administrator. Comments: Facility staff reminded to visit the public website for information from the department, inspector will continue to forward notices. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. POC due within 10 days- 1-15-2022

Violations

22VAC40-73-260-C

Based on observation and staff interviewed, the facility failed to ensure the first aid and cardiopulmonary resuscitation (CPR) listing was posted in the facility.

Evidence

On 12-15-21, staff #8 was asked where the first aid and CPR list was posted. Staff # 8 looked at the posting on various boards in the medication room but was not able to locate the list of staff who are certified in first aid and CPR. Staff #8 stated not knowing where the listing could be.
Staff #1 and CS-1 acknowledged the facility’s first aid and CPR listing was posted on the day of the inspection.

Plan of correction

Assistant Administrator will update and post 1st Aid & CPR certified staff listing which will include a DO NOT REMOVE warning. List will be posted in Nursing Office, Break room and Kitchen January 21, 2022

22VAC40-73-290-A

Based on observation and staff interviewed, the facility failed to ensure the written work schedule included the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time.

Evidence

On 12-15-21 the dietary scheduled provided to the inspectors documented the first name only of staff working.
Staff #1 acknowledged the dietary schedule did not include all required information.

Plan of correction

Assistant Administrator will update dietary schedule template to include legend with first and last name of dietary staff. January 13, 2022

22VAC40-73-290-B

Based on observation and staff interviewed, the facility failed to ensure it posted the name of the current on-site person in charge, as provided for in the regulation, in a place in the facility that is conspicuous to the residents and to the public.

Evidence

On 12-15-21 at 06:50 a.m., the inspector looked for the posting of the staff person in charge when signing into the facility. Upon walking down the hallway, the inspector observed staff #3, #6 and #7 in staff’s breakroom and inquired who was in charge?
On the way to the nursing station/ medication room, staff # 3 stated being “the med tech”. The bulletin board located outside the medication room listed staff names and shifts. The names of the individuals listed was for the day shift on 12-14-21.
Staff #1 acknowledged the staff in charge was not posted as required.

Plan of correction

Lead RMA on each shift will be responsible for updating nursing staff board to reflect correct on-site person in charge in the absence of administrative staff. January 21, 2022

22VAC40-73-320-B

Based on record reviewed and staff interviewed, the facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually for a resident as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
On 12-15-21, a review of resident #2’s record revealed the resident’s TB was last dated 11-30-20.
CS-1 acknowledged resident #2’s TB information was not updated.

Plan of correction

Resident TB date ledger will be established and updated by Nurse overseer as TB’s are given or assessment done January 21, 2022

22VAC40-73-610-C

Evidence

On 12-15-21 during the breakfast meal observation, residents were observed being served food in 2-ounce containers. The strawberry yogurt was served in 2 ?ounce clear plastic containers. Also observed was cut strawberries served in the 2- ounce cup, each cup contained 3 or 4 quartered section of a strawberry. Also observed were mini muffins and a hardboiled egg cut in half. Oatmeal was observed at the second seating. The menu documented the following: Yogurt, Assorted Muffins, 1 Boiled egg, ? C cold cereal or Oatmeal, fruit and coffee/milk/juice.
Staff #5 was inquired as to why the resident were being served in 2-ounce plastic containers and why the serving sizes were not the recommended serving size for adults? Staff stated doing what was instructed by the boss/ the administrator/licensee. Staff stated being aware of a previous conversation with the inspector regarding the requirements for serving for the residents.
The second seating lunch meal observation, residents were served a chef salad as documented on the menu. The size of the salad observed was that of a small side salad and included two to three, I inch long and ? wide strips of meat, julienne carrots, ice berg lettuce, and a half boiled egg. The lunch menu posted noted the following: Chef’s Salad, fruit/ coffee/tea/lemonade.
The dinner meal observation, residents were served, strips of baked tilapia, two potato wedges, cole slaw served in 2- ounce plastic containers, cornbread, macaroni and cheese; three residents were observed with split pea soup and corn bread only. The menu posted noted the following; Cajun Baked Fish baked macaroni and cheese, potato wedges, cole slaw, split pea soup, corn bread, chocolate cake, coffee/tea/lemonade.
The facility’s nutrition review dated January 29, 2021 documented facility menu do not contain 5 servings of vegetables and/or fruits; requested facility review each day’s menu and add items. Recommendations provided to facility for residents with puree diet: to serve entire meal at breakfast, lunch and dinner, whether the individual eats everything every time or not; cannot just serve a bowl of cereal or puree soup. Individuals should have option of tasting a variety of meal meals; plate each individual item for a meal. The report also documented some residents had experienced weight decline and/or are Hospice Care.
On 12-15-21, during the medication pass observation with staff #3, there were six residents on the assisted living cart who were receiving a supplement during the breakfast meal.
Interviews with residents on 12-15-21, several purchase food from outside the facility, some have snack items in their rooms and some also purchase items from the vending machine located in the facility.

Plan of correction

8 ounce plastic bowls will be purchased by facility to ensure the amounts served met the guidelines set forth by the USDA. USDA Dietary Guidelines for Americans 2020-2025 printed for staff referencing. Dietary Staff in-serviced on dietary guidelines and the importance of residents receiving daily/weekly allowances, Specifically dietary patters for ages 19-59 and ages 60 and over. Any and all dietary nutritional oversight reports will be reviewed by Nurse Overseer and Administration to ensure recommendations are followed and implemented. March 1, 2022

22VAC40-73-620-B

Based on document review and staff interviewed, the facility failed to ensure it took action in response to the recommendations noted in the nutritional oversight report and document such information in the resident’s record.

Evidence

On 12-15-21, the inspector inquired of staff #1 the recommendations provided the facility as documented in the January 29, 2021 nutritional report. Staff #1 was informed of the dieticians report that documented forwarding to staff #1, a 5 week, 2 entree/meal menu to staff #1 for menu planning ideas. The requirements for provided full meal and providing sauces, gravies, butter, jellies, etc. as appropriated for the food item on foods for moisture and for extra needed calories. The inspector did not see any of the recommendations from the dietician’s report on the day of the inspection.
The inspectors reminded staff #1 and CS-1 of the regulation regarding following up on the recommendations provided to the facility. Staff also informed of the regulation requirement for meals for adults in the facility unless the resident’s physician or other prescriber’s have otherwise written an order for something different.
Staff acknowledged receiving a copy of the dietician’s January 2021 review.

Plan of correction

22VAC40-73-690-G

Evidence

On 12-15-21, resident #3’s pharmacy review completed in August 2021 recommended resident’s Hydrocortisone cream be discontinued. The record did not contain documentation of the facility’s follow-up on the recommendation.
CS-1, the individual who completes the Healthcare oversight, was asked who was responsible for ensuring the recommendations of the consults were completed and documented in the resident’s record. CS-1 stated the facility staff should be reviewing the recommendations and providing information to the resident’s physician.
Staff #1 acknowledged no action was taken of the pharmacy’s recommendation for the aforementioned resident’s medication.

Plan of correction

Nursing staff will be in-serviced by Nurse Overseer on the appropriate actions needed in response to pharmacy overview recommendations. RMA’s will review recommendations and fax appropriate physician, making note on pharmacy review form and/or physician’s order form of recommendations by pharmacy and request physician’s response. February 15, 2022

22VAC40-73-870-A

Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair and kept clean.

Evidence

On 12-15-21 during a tour of the facility with staff #1, the entrance area to the bathtub in room #52 was observed to be cracked and in need of repair. The carpet in bedrooms and foyer area in rooms #29-A, #11, #13, and #21 were observed with heavy dark black stains and in need of cleaning. The vents in room #29 and the nursing station/medication room was observed with heavy coating of grey substance. The refrigerator in room # 29 was observed to have dark brown rusted like stains. The wall in the entrance area to the nursing station/medication room needs painting, the metal area of the wall is exposed. The wood floor in the entrance way of the medication room/nursing station was observed to be cracked and splitting with loose pieces of wood in the area.
Staff #1 acknowledged facility conditions observed.

Plan of correction

Maintenance Request Form will be available to staff and residents to report repairs needed. Maintenance staff will pick up request forms weekly and complete requests to ensure repairs are done in a timely manner. Carpet in apartments with stains will be cleaned by a profession company. (All carpets will eventually be replaced) March 1, 2022

22VAC40-73-960-C

Based on observation and staff interviewed, the facility failed to ensure the telephone number for Poison Control Center was posted by the telephone in the medication room/nursing station.

Evidence

On 12-15-21, the facility’s pharmacy review dated 7-14-21 documented the poison control phone number was not posted. Staff # 3 was inquired where the telephone listing for emergency was posted. Staff pointed to the bulletin board in the medication room. The Poison control number was not posted and the number could not be located by staff.
Staff #3 acknowledged the Poison Control Center number was not posted or available on the day of the inspection.

Plan of correction

New Poison Control Center phone numbers labels will be placed on all desk phones throughout the facility to replace the already existing ones that are peeling off. All staff will be in-serviced on the location of important/emergency phone numbers location in the nurse’s station. March 1, 2022

22VAC40-73-980-A

Based on observation and staff interviewed, the facility failed to ensure the first aid kit included all required items.

Evidence

On 12-15-21, the first aid kit in medication room/nursing station did not include an assortment of Band-Aids.
The first aid kit for the facility van did not include adhesive tape.
Staff #2 and CS-1 acknowledged the facility first aid kits did not include all required items.

Plan of correction

Request form for items needed to ensure 1st Aid kit is fully stocked will be added to 1st Aid checklist book, so staff may get list of items needed to Assistant Administrator for purchase. January 21, 2022

December 15, 2021Complaint survey1 violation

Inspection dates

Dec. 15, 2021

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

An unannounced complaint inspection was conducted on 12-15-21 in response to a complaint that was received by the regional licensing office. Staff interviews and records reviews were conducted regarding an allegation of resident care. The The information gathered during the investigation did not support the allegation, so the complaint is determined to be "not valid". There were other violations cited during the inspection. Please complete the columns for "description of action to be taken: and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendars of receipt. If you have any questions, contact the licensing inspector at (757) 439-6815. Plan of correction is due by 1-9-22

Violations

22VAC40-73-70-A

Based on documents reviewed and staff interviewed, the facility failed to ensure it reported to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.

Evidence

On 12-15-21 during interview with CS#1, for reported wound and resident care for resident #1, CS #1 informed the inspectors resident #2 also was identified with wound care needs on 10-26-21.
A review of resident #1 and 2’s Progress Noted documented residents were receiving Hospice services. Progress Notes dated 10-26-21 at 11:42 a.m., documented ?resident has a breakdown on bottom, hospice called CS #1 also contacted.
Staff #4 also documented on 10-26-21 at 10:40 p.m., ?resident had pressure sore for weeks now CNAs was applying calmoseptine to the buttocks, pressure grew to the size of a quarter & about 1 to1 ? inch depth covered with 4 X 4 gauge pad and the correct border sacrum dressing.? Staff also documented informing staff in charge to contact Hospice and not knowing if agency had left supplies for dressing change.
Resident #1’s record and facility communication log, did not include documentation by staff or agency of resident #1? s sacral wound prior to staff #2’s documentation on 10-26-21.
Resident #2’s record Progress Notes documented on 9-26-21 at 8:00 p.m. by CS #1, a ?sacral wound measurement done, area of tunneling healed??
Staff #4 documented in resident #2’s Progress Notes on 10-26-21 at 11:10 p.m., ?resident had pressure sore for weeks, tried my best to keep it dry with 4 X4 guage pad & the correct dressings?? Staff also documented informing charge nurse to contact hospice, continued monitoring and ?the wrong dressing is being applied to the buttocks of this resident??
CS #1 documented on 10-26-21, ?dressing changes done as ordered 5x weekly and as needed by RN on weekends. ?.staff to notify Hospice if dressing comes off.
The facility did not report resident #1’s sacral ulcer documented 10-26 21 to the licensing office. The facility also did not report resident #2’s sacral ulcer that was documented as healed on 9-26-21. The facility also did not report resident #2’s sacral ulcer documented in the record on 10-26-21.
Staff #1 reminded to forward to the licensing office reportable incidents.

Plan of correction

Nursing and Administrative staff will be in-serviced on VDSS regulation regarding reporting any major incidents that negatively affects or threatens the life, health or welfare of any resident. Staff will be instructed to immediately report any and all questionable wounds, visits from the fire department, Police, Adult Protective services or resident being sent to ER to Nursing Supervisor and Administrative Staff to ensure proper care is started in a timely manner and reported to VDSS if applicable. Nursing staff will be instructed to utilize the 24 hour communication log as well as verbal notification of these incidents to ensure all nursing staff are aware. February 15, 2022

October 5, 2021Complaint survey1 violation

Inspection dates

Oct. 5, 2021 , Oct. 12, 2021 and Dec. 15, 2021

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

An non-mandated complaint investigation was conducted on 10-5-21. The administrator was contacted but was not present, the staff person in charge was provided a list of the requested documents. The licensing inspector emailed the staff person-in-charge a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on 12-15-21. The evidence gathered during the investigation supported the non-compliance with standards or law, and violations were issued. Any violations not related to the but identified during the course of the investigation can be found on the violation notice. Please complete the columns for "description of action to be taken: and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendars of receipt. If you have any questions, contact the licensing inspector at (757) 439-6815. Plan of correction is due by 1-9-22.

Violations

22VAC40-73-280-A

Based on documents reviewed and staff interviewed, the facility failed to ensure it had staff adequate in knowledge, skills and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental and psychological well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with this chapter (Part IV-Staffing and Supervision).

Evidence

The residents? roster provided for a complaint of insufficient staff in the facility documented 43 resident. The resident roster documented the following acuity levels: (a) 6 residents receiving hospice services, (b) 3 non-ambulatory residents, (c) 14 residents documented as fall risk and (d) 4 residents requiring 30- minute checks.
According to collateral reports and interviews, there was only 1 staff in the facility on the night of 9-11-21 for the 10 p.m. to 6 a.m shift.
The staff roster provided documented 2 staff for the 10 p.m. to 6 a.m. shift on the night of 9-11-21. Interviews with various staff revealed there was only 1 staff in the facility to provide care for
According to interviews and police report, calls were made management staff and the administrator/licensee. There was no response from management staff. Contact was made with the administrator/licensee who was informed of the staffing shortage at the facility. The report documented, the administrator- licensee stated living two hours away ? there other staff who lived closer and wanted to know what did the officer what him to do.
Interview with staff revealed, a resident locked themselves in another resident’s bathroom and took apart the doorknob and staff needed the officer’s assistance because staff could not open the bathroom door.
Staff #1 acknowledged facility did not have sufficient staff on night of 9-11-21

Plan of correction

Employment ads will be placed on Zip Recruiter, Linked In and Indeed to advertise for additional staff. (already done) Facility has contracted with a local nursing agency to assist with filling openings in the direct Care/C.N.A. schedule. (already done) Administrative staff will continue to pick up shifts in which there is no coverage until staffing is sufficient. Facility will hire qualified candidates to alleviate the need for OT by current staff and to fill shifts in need of proper staffing, January 21, 22 and ongoing

January 31, 2021Inspection3 violations

Inspection dates

Jan. 31, 2021

Areas reviewed

Part II- Administration and Administrative ServicesPart III- PersonnelPart IV- Staffing and SupervisionPart V- Admission, Retention and Discharge of ResidentsPart VI- Resident Care and Related ServicesPart VII-Resident Accommodations and Related ProvisionsPart VIII- Buildings and GroundsPart IX- Emergency Preparedness22VAC 40-90

Comments

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 1-14-21 and concluded on 1-26-21. The assistant to the administrator was contacted by telephone to initiate the inspection. The assistant to the administrator reported that the current census was 45. The inspector emailed the assistant to the administrator a list of items to complete the inspection. The inspector reviewed three resident records, three staff records, staff schedules, sworn disclosure and background checks of new staff since last inspection, fire drills and emergency preparedness documents, fire and health inspections, healthcare oversight/nutrition/ and pharmacy report for sample residents. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations

22VAC40-73-320-A

Based on a review of resident records and staff interview, the facility failed to ensure the physical examination form included all required information for one of three records.

Evidence

Resident #2’s physical examination document dated 6-2-20 did not include the address and telephone number, height, weight and blood pressure.
Staff #1 acknowledged the information was not documented on the physical examination form.

Plan of correction

Facilities History & Physical Form will be updated to state ?All information is required for admission. Paperwork will be returned and admission delayed if information is missing? Please write N/A if not applicable A disclaimer will be added to the facilities history and physical form for resident/family/POA to sign/date stating they are aware that the entire form must be completed and signed by a licensed physician. In the event information is missing, the paperwork may be returned for completion and admission will be delayed.

22VAC40-73-450-C

Based on a review of resident records and staff interview, the facility failed to ensure the individualized service plan (ISP) include all assessed and documented need for two of three residents.

Evidence

Resident #1’s uniform assessment instrument (UAI) dated 3-17-20 documented bowel and bladder need as greater than weekly and a notation of the use of briefs. Resident’s individualized service plan (ISP) dated 3-17-20 did not include dua ce p a ( S ) dated 3 0 d d ot c ude these assessed needs. Resident’s medication administration record (MAR) for December 2020 documented resident is administered a nutritional supplement twice a day and “family supply” supplement is not documented on the ISP. In addition, the MAR documented resident’s Risamine Ointment is kept at bedside, this is not documented on the resident’s ISP.
Resident #2’s physical examination dated 6-2-20 documented physical and occupational therapy recommended. A physician’s order dated 7-14-20 documented “d/c pt/ot as per resident + family request”. These services were not documented on the ISP dated 6-3-20 and updated 7-7-20.
Staff #1 acknowledged the services assessed and documented were not on the residents ISP.

Plan of correction

Nursing staff will be in-serviced by RN (Nurse Overseer) on the importance of relaying information required to be included on resident’s ISP’s to Administrator, Assistant Administrator and RN to ensure changes are made in a timely manner. An ISP Changes Needed Binder will be kept in the Nursing office for staff to place copies of new orders, discontinued orders for home health services, hospice services, equipment changes, level of care changes, diet changes, allergy changes, family providing supplies, etc. to ensure ISP’s are kept up to date. ISP Changes Needed Binder will be brought to weekly Plan of Care Meeting to ensure changes are made in a timely manner.

22VAC40-73-450-D

Based on record review and staff interview, the facility failed to ensure when hospice care is provided to a resident, the services provided shall be included on the individualized service plan for a resident.

Evidence

Resident #2’s record documented physician’s order dated 1-5-2021 recertifying resident’s hospice services with a local agency for 01-31-21 to 0-3-03-21. Resident’s individualized service plan (ISP) dated 6-3-20 and updated 7-7-20 did not document resident receiving hospice care services reflecting a change in the resident's condition.
Staff #1 acknowledged resident #2’s ISP did not include hospice care services.

Plan of correction