Virginia DSS · Assisted Living Facility

Dominion Village at Poquoson

📍 531 Wythe Creek Road, Poquoson, VA, 23662

ID 45785One Year licenseActive
9
Inspections
On record
9
With violations
Visits that cited something
0
Clean visits
Nothing cited
55
Violations cited
Individual findings
41
Standards cited
Distinct rules
3
Complaint visits
Prompted by a complaint

Dominion Village at Poquoson was inspected 9 times between May 6, 2021 and May 7, 2025 by the Virginia Department of Social Services. 9 of those visits ended with violations cited and 0 with none. Across that history VDSS cited 55 violations under 41 distinct standards. 3 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. 8 of these 9 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
06/30/2026
Administrator
Reyna Godin
Licensing inspector
Alyshia Walker
Inspector phone
(757) 670-0504
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

9

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

May 7, 2025Inspection11 violations
Inspection dates
05/07/2025, 05/08/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/7/2025 (8:22 am- 2:15 pm), 5/8/2025 7:37 am- 8:35 am) 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: 22 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia/Walker@dss.virginia.gov
Violations
22VAC40-73-610-B
Based on observation and interview, facility failed to ensure menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents and any substitutions or additions shall be recorded on the posted menu.
Evidence
  1. During the inspection of the facility with Staff #1 on 5/7/2025, there was no menu posted on the memory care unit.
  2. Staff # 1 acknowledged the menu was not posted.
Plan of correction
The Dining Services Director (DSD) promptly posted in a clearly visible and accessible location for all residents. A designated Memory Care staff member will check each morning to ensure the posted menu is current. The Executive Director (ED) will check weekly that the current menu is posted.
22VAC40-73-325-B
Based on records reviewed, the facility failed to ensure that a fall risk assessment was reviewed and updated after every fall.
Evidence
  1. Resident # 3 had documented falls on 9/3/2024, 9/5/2024, 10/15/2024, 10/20/2024, 10/22/2024, 11/6/2024, 12/23/2024, and 4/15/2025. There were no corresponding fall risk assessments in the resident file for the falls.
  2. Staff # 4 acknowledged there were no fall risk assessments in the resident file for the above-mentioned falls.
Plan of correction
Failure to update fall risk assessment following a resident fall The Resident Care Coordinator (RCC) will schedule and conduct a training for all Licensed Practical Nurses (LPNs) and Registered Medication Aides (RMAs) to emphasize the importance of reviewing and updating fall risk assessments immediately following any resident fall. The Resident Care Coordinator (RCC) will conduct weekly audits of resident files to verify that fall risk assessments are completed and updated after each fall incident. Ongoing education and reinforcement of this requirement will be incorporated into staff meetings and onboarding for new clinical staff. The Executive Director (ED) will perform monthly spot checks of resident records to monitor compliance and provide oversight of the auditing process.
22VAC40-73-680-I
Based on resident review and review of the Medication Administration Record (MAR), the facility failed to document the effectiveness of the as needed (PRN) medication.
Evidence
  1. The April 2025 MAR for Resident # 7 documented the resident was administered the PRN Lorazepam 1 mg tablet on 4/9/2025 at 7:30 pm, 4/10/2025 at 4:32 pm, and 4/14/2025 at 5:45 pm. There was no documentation regarding the effectiveness of the medication.
Plan of correction
The Resident Care Coordinator (RCC) will schedule and conduct a mandatory training session for all Licensed Practical Nurses (LPNs) and Registered Medication Aides (RMAs) to reinforce the importance of accurate PRN documentation, including how to properly record the reason and effect of each administration. The Health and Wellness Director (HWD) will implement daily at shift change a review process by LPNs and RMAs to ensure PRN documentation is complete and accurate. The Resident Care Coordinator or designee will utilize electronic monitoring daily to ensure all PRN documentation is complete and accurate.
22VAC40-73-680-I
Based on a review of resident records the facility failed to include all required information on the medication administration record (MAR), including date prescribed, drug product name, strength of the drug, dosage, diagnosis, condition, or specific indications for administering the drug or supplement, route (e.g., by mouth), and how often medication is to be taken.
Evidence
  1. The April 2025 MAR for Resident # 7 did not include the diagnosis, condition, or specific indication for administering the drug for the following medication: escitalopram tab 5 mg, and Lorazepam 1 mg tablet.
  2. The April 2025 MAR for Resident # 5 did not include the diagnosis, condition, or specific indication for administering the drug/supplement for the following: Boost VHC Vanilla 8 oz, Levothyroxine tab 150 mcg, Melatonin tab 10 mg, and Triad wound paste dressing
  3. The April 2025 MAR for Resident # 3 did not include the diagnosis, condition, or specific indication for administering the Melatonin tablet 3 mg, Mirtazapine tablet 7.5 mg, and Quetiapine tablet 25 mg.
Plan of correction
The Resident Care Coordinator (RCC) will conduct a full audit of all current MARs to identify any missing diagnosis, condition, or specific indications for each medication or supplement. The Resident Care Coordinator (RCC) or designee will collaborate with prescribing physicians or nurse practitioners to obtain and document the required information for each medication. The Resident Care Coordinator (RCC) will schedule and conduct a training for all Registered Medication Aides (RMAs) and Licensed Practical Nurses (LPNs) on proper MAR documentation, emphasizing the importance of including indications. The Resident Care Coordinator (RCC) and a designated team member will conduct regular audits of Medication Administration Records and medication carts to verify that all prescribed medications have a diagnosis. Prescribers will be contacted immediately to obtain missing information from prescribers promptly. The Health and Wellness Director will conduct monthly audits of prescribers' orders to ensure they have a diagnosis.
22VAC40-73-450-F
Based on resident record review the facility failed to have the ISP signed and dated by the licensee, administrator, or designee and by the resident or his legal representative.
Evidence
  1. The ISP for Resident # 4 dated 5/14/2024, did not contain a resident or legal representative signature.
  2. The ISP for Resident #7 dated 4/10/2025, did not contain signatures of the licensee, administrator, or designee and by the resident or his legal representative.
Plan of correction
The Resident Care Coordinator (RCC) and the Health and Wellness Director (HWD) will conduct a comprehensive audit of all current residents’ ISPs to identify any that have not been reviewed or updated within the past 12 months. Any ISP out of compliance, the RCC will immediately complete an updated assessment and plan revision and ensure all updates are properly documented, signed, and dated by the appropriate personnel and the resident or their legal representative. The Resident Care Coordinator (RCC) will utilize an electronic tracking system to flag upcoming ISP review deadlines at least 30 days in advance. The Health and Wellness Director (HWD) will monitor monthly for compliance.
22VAC40-73-450-F
Based on record review and interview with staff, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months and as needed for a significant change in the resident’s condition.
Evidence
  1. The most recent ISP for Resident # 4 dated 5/14/2024, was not updated to include the wound care services the resident was receiving or the change in diet which became effective 3/19/25. The ISP stated the resident had a regular diet when the resident’s diet changed to mechanical ground.
  2. Staff # 1 acknowledged the ISP had not been updated to reflect the changes in the resident’s condition.
Plan of correction
The Resident Care Coordinator (RCC) and Health and Wellness Director (HWD) have initiated a comprehensive audit of all current ISPs to ensure they are up to date and accurately reflect any changes in residents’ conditions or care needs. Any discrepancies identified during the audit are being addressed immediately, and ISPs are being updated accordingly. To reinforce compliance, a training session has been scheduled for May 29, 2025, for all Licensed Practical Nurses (LPNs) and Registered Medication Aides (RMAs). The Executive Director (ED) will spot check monthly/ongoing to ensure compliance.
22VAC40-73-550-F
Based on observation the facility failed to ensure that the rights and responsibilities of residents shall be printed in at least 14-point type and posted conspicuously in a public place.
Evidence
  1. During a tour of the facility on 5/7/2025, the licensing inspector observed that the Rights and Responsibilities of Residents were not posted.
  2. Staff # 1 acknowledged the Resident Rights and Responsibilities were not posted.
Plan of correction
The Resident Rights were printed and posted on the Bulletin Board. The Resident Rights posting is to be monitored during daily rounds, team is to make the Executive Director (ED) aware if the posting is removed. In the event the Resident Rights are removed, the Life Enrichment Director (LED) to repost immediately. The Executive Director (ED) will spot check monthly
22VAC40-73-860-G
Based on observation and staff interviewed, the facility failed to ensure the hot water taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F.
Evidence
  1. During an inspection of the facility on 5/8/2025, the hot water temperature in the bathroom shared between resident rooms 18 B and 17 B measured 125.7 F, the bathroom shared between resident rooms 16 B and 15 B measured 129.5 F, and the bathroom shared between resident rooms 4 A and 3 A measured 122.2 F.
  2. Staff # 2 acknowledged the readings for the hot water temperatures.
Plan of correction
A facility-wide inspection of all resident-accessible hot water taps to measure current water temperatures will be conducted by the Environmental Services Director (ESD). The Environmental Services Director (ESD) will implement a bi-weekly schedule for testing water temperatures at various resident-accessible taps. The Environmental Services Director (ESD) will be responsible for conducting temperature checks, adjusting equipment, and maintaining logs. All Direct Care Staff (DCS) will be trained to report any resident complaints or concerns related to water temperature. The Executive Director (ED) will spot-check water at taps monthly to ensure ongoing compliance with the standard.
22VAC40-73-930-B
Based on record review, the facility failed to ensure there is a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal.
Evidence
  1. During the facility inspection with Staff # 1, the Licensing Inspector pulled the call bell in the bathroom for resident room 19 B. The call bell did not work.
  2. The Licensing Inspector pulled the call bell in the shared bathroom for resident room 16 B. The call bell in the bathroom did not work.
  3. The Licensing Inspector looked for the call bell in the bedroom for resident room 16 B. The call bell was missing.
  4. The Licensing Inspector pulled the call bell for the bathroom for resident room 14 B. The call bell did not work.
  5. The Licensing Inspector looked for the call bell in the bedroom for resident room 10 A. The call bell was missing.
  6. The Licensing Inspector pulled the call bell in the shared bathroom for resident room 10 A. The call bell in the bathroom did not work.
  7. Staff # 1 acknowledged all the above instances regarding the missing or nonworking call bells.
Plan of correction
The Environmental Services Director will conduct a full evaluation of the current signaling system. A weekly maintenance schedule will be implemented to test the signaling system and ensure it remains fully functional. The Environmental Services Director (ESD) or designee is responsible for system inspections, maintenance, and documentation. The Executive Director (ED) spot checks the system weekly. The Environmental Services Director (ESD) will schedule and conduct training for all staff to respond promptly and report any issues with the signaling system.
22VAC40-73-310-H
Based on records reviewed and staff interviewed, the facility failed to ensure in accordance with 63.2-1805 D Code of Virginia, it did not admit or retain individuals with any prohibitive conditions without required documentation.
Evidence
  1. Resident # 7’s medication administration record document the resident was prescribed Lexapro 5 mg. There was no psychotropic treatment plan in the resident’s file for the medication.
  2. Staff #1 acknowledged there was no psychotropic treatment plan in the resident record for the medication.
Plan of correction
A psychotropic treatment plan has been completed and sent to the resident’s primary care physician for review and signature. Documentation has been placed in the resident’s file to ensure compliance with regulatory requirements. The Resident Care Coordinator (RCC) and Health and Wellness Director (HWD) will conduct an internal audit of all resident files to ensure that psychotropic treatment plans are current and complete. The Health and Wellness Director (HWD) will schedule and conduct a training session with LPNs and RMAs. The Executive Director (ED) will perform monthly spot checks of resident files to ensure ongoing compliance and provide oversight of the audit and training processes.
22VAC40-73-520-I
Based on observations made during a tour of the building, the facility failed to ensure the current month's activity schedule shall be posted in a conspicuous location in the facility.
Evidence
  1. During the on-site inspection on 5/8/2025, there was no posted activities calendar in the memory care unit. The activity calendar on the monitor in the assisted living portion of the building displayed an activity calendar for April 2025.
  2. Staff #1 acknowledged the current activities calendar was not posted.
Plan of correction
The Life Enrichment Director (LED) posted a current monthly activity schedule in a location clearly visible and accessible to all residents. The administrator or designee will review the activity schedule monthly to ensure it is properly posted. The Executive Director (ED) will conduct a monthly audit to verify schedule accuracy, posting, and retention.
June 7, 2024Inspection1 violation
Inspection dates
06/07/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Other Self-Report Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/7/2024 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 4/23/2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-460-D
Based on facility self-report, staff interview and a review of resident records, the facility failed to provide supervision of resident schedules, care and activities.
Evidence
  1. The facility provided a self-report on 4/23/2024 which stated Resident #1 (who resides on the safe, secure, unit) was observed walking out of another resident’s room holding a cleaning chemical. Resident #1’s shirt was reportedly wet, and she stated she drank some of the fluid. Resident was sent to the Emergency Room for evaluation.
  2. Resident #1’s Individualized Serve Plan dated 4/15/2024 stated the resident is disoriented to some spheres all of the time and that staff reorient the resident to time and place as needed.
  3. Both Staff #1 and #2 acknowledge the incident occurred.
Plan of correction
Steps to correct the noncompliance with the standard: Cleaning supplies were removed. All rooms checked. Meeting held with family that brought cleaning supplies in. All rooms have lock box under bathroom sink for personal supplies. Measures to prevent the noncompliance from occurring again: MCD to monitor supplies that are brought in by family members. MCD to review with families acceptable items to bring and what not to bring. Person(s) responsible for implementation of each step and/or monitoring preventative measures MCD to do a weekly room check and ED to spot check
June 7, 2024Inspection9 violations
Inspection dates
06/07/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/7/2024 9:00 am -1:30 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 4 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 3 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-250-C
Based on a review of staff records, the facility failed to verify that each staff person has received a copy of his or her current job description.
Evidence
  1. Staff member #3’s (D.O.H. 12/16/2023) file contained a job description which was signed on the date of the inspection, 6/7/2024.
Plan of correction
Steps to correct the noncompliance with the standard: Job descriptions to be signed on hire and annually Measures to prevent the noncompliance from occurring again: BOM will use orientation checklist to ensure everything is completed timely Person(s) responsible for implementation of each step and/or monitoring preventative measures BOM to audit all files, job descriptions that are signed online will be printed and put in file. Any missing will be reported to ED. ED will review at least quarterly
22VAC40-73-290-B
Based on observation, the facility failed to ensure the posting of the name of the current on-site person in charge.
Evidence
  1. On the date of the inspection 6/7/2024, the posting of the on-site person in charge was not accurately updated to reflect the person who was in charge of the building at the time the inspector entered the building. The welcome board reflected the date as being June 5, 2024.
Plan of correction
Steps to correct the noncompliance with the standard: LED/charge nurse to make sure daily posting board is current with date and team members Measures to prevent the noncompliance from occurring again: Nurse on Duty/LED or designee to update board daily as part of the daily routine Person(s) responsible for implementation of each step and/or monitoring preventative measures LED or designee to ensure board is completed daily as part of daily management rounds. ED to spot check
22VAC40-73-450-E
Based on resident record review and interview with staff, the facility failed to have the ISP signed and dated by the licensee, administrator, or designee and by the resident or his legal representative.
Evidence
  1. Resident #1 has an ISP dated 2/11/2024. There were no signatures on the ISP of the resident or his legal representative.
  2. Resident #2 has an ISP not dated 9/28/2023. There were no signatures on the ISP of the resident or his legal representative.
  3. Resident #3 has an ISP dated 4/15/2023. There was no signature on the ISP of the resident or his legal representative.
  4. Resident #4 has an ISP dated 8/23/2024. There was no signature on the ISP of the resident or his legal representative.
Plan of correction
Steps to correct the noncompliance with the standard: HWD/ED to schedule care meetings monthly/as needed to ensure signatures obtained timely Measures to prevent the noncompliance from occurring again: HWD/ED to conduct audit of all resident files to ensure all ISPs have required signatures. HWD or designee will review care plans and set up family meetings. HWD/ED to utilize tickler system Person(s) responsible for implementation of each step and/or monitoring preventative measures HWD or designee to review weekly. ED to review at least quarterly to ensure completion
22VAC40-73-940-A
Based on the record review the facility failed to ensure an assisted living facility shall comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determine by at least an annual inspection by the appropriate fire official.
Evidence
  1. The facility’s record contains an annual fire inspection completed on 5/5/2023.
  2. Staff # 4 acknowledged the facility’s record of the last fire inspection completed is dated 05/5/2023.
Plan of correction
Steps to correct the noncompliance with the standard: Began calling for annual fire inspection the end of April as we knew we were due in May. At this time inspection not completed, but we will continue to call Measures to prevent the noncompliance from occurring again: ESD or designee will begin calling for inspection 2 months prior to being due. ESD or designee will continue to call and schedule until completion Person(s) responsible for implementation of each step and/or monitoring preventative measures ESD to ensure fire inspection is scheduled annually and as needed. ED will review at least quarterly for compliance
22VAC40-73-550-G
Based on the review of facility records and staff interviews conducted the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities are reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person.
Evidence
  1. The file presented to the Licensing Inspector at the time of inspection for Resident #1 contained a review of resident’s rights dated 1/19/2023.
  2. The file presented to the Licensing Inspector at the time of inspection for Resident #2 contained a review of resident’s rights dated 5/16/2019.
  3. The file presented to the Licensing Inspector at the time of inspection for Resident # 4 did not contain a signed copy of the resident’s rights.
Plan of correction
Steps to correct the noncompliance with the standard: Resident rights to be reviewed on move-in and annually Measures to prevent the noncompliance from occurring again: BOM or designee will conduct audit all resident files to ensure all residents have Resident Rights signed. Any missing will be reported to ED. BOM or designee will utilize move- in checklist to ensure completion on move in. BOM or designee will utilize tickler to ensure signature is obtained for each resident/POA annually. ED will review at least quarterly Person(s) responsible for implementation of each step and/or monitoring preventative measures BOM or designee to audit files to ensure completion. BOM or designee will utilize move in checklist on move in and use a tickler to ensure annual completion
22VAC40-73-980-A
Based on observation and staff interviewed, the facility failed to ensure the first aid kits were checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date.
Evidence
  1. On 6/7/2024 during the inspection of the First-Aid kit for the building, the hand sanitizer had an expiration date of 9/1/2023. The First-Aid kit for the van contained hand sanitizer with an expiration date of 9/1/2023 and antibiotic alcohol pads with an expiration date of 4/2023.
  2. Staff members #1 and #4 both acknowledged the above-mentioned items were expired.
Plan of correction
Steps to correct the noncompliance with the standard: Items replaced on site in first aid kit. Measures to prevent the noncompliance from occurring again: Night nurse or designee to utilize checklist to check first aid weekly and replace items as needed LED/MCD or designee will utilize checklist to check first aid kit on bus weekly and replace items as needed. Any items missing or expired will be reported to ED. Person(s) responsible for implementation of each step and/or monitoring preventative measures Night nurse, MCD/LED or designee to complete checklist weekly. ED will review at least quarterly
22VAC40-73-640-A
Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes.
Evidence
  1. A review of the Narcotic Inventory Verification Form for the memory care and Assisted Living documented staff failed to ensure counts of all controlled substances occurred between oncoming staff and off going staff.
  2. Staff members #1 and #2 acknowledged the forms did not document narcotic medication counts were conducted during the change of each shift.
Plan of correction
Steps to correct the noncompliance with the standard: Training set up with nurses on total narc count forms. All med techs will be in-services on Narcotic medication policy to include counting at start and end of each shift. Measures to prevent the noncompliance from occurring again: HWD/ED or designee to review narc forms weekly to ensure forms are completed entirely. Any blanks will be reported to ED. Person(s) responsible for implementation of each step and/or monitoring preventative measures Charge nurses or designee to ensure to sign total count form. HWD or designee to review weekly to ensure compliance. ED will review at least quarterly
22VAC40-73-350-B
Based on review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender.
Evidence
  1. Resident # 3 had an admission date of 3/17/2024 and the Sex Offender Screening was conducted on 3/19/2024.
Plan of correction
Steps to correct the noncompliance with the standard: Sex offender screening to be done prior to admission Measures to prevent the noncompliance from occurring again: BOM or designee to utilize move-in checklist and ensure completed prior to admission Person(s) responsible for implementation of each step and/or monitoring preventative measures BOM or designee to conduct an audit of all resident files to ensure all resident files have completed sex offender screening. BOM or Designee to utilize move- in checklist. Any resident files missing sex offender screening will be reported to ED. ED to review move-in checklist with all new move ins and quarterly.
22VAC40-73-640-D
Based on observation and staff interviewed, the facility failed to ensure the pharmacy reference book, drug guide, or medication handbook was no more than two years old as reference for staff who administer medications.
Evidence
  1. The pharmacy drug guide on-site on 6/7/2024 was dated 2021.
  2. Staff #2 acknowledged the pharmacy reference book was not dated within the past two years.
Plan of correction
Steps to correct the noncompliance with the standard: 2024 Drug book ordered and will be placed on medication cart. Measures to prevent the noncompliance from occurring again: HWD or designee to review monthly during med cart audit to ensure current book is on med cart. Any missing drug book will be reported to ED. Person(s) responsible for implementation of each step and/or monitoring preventative measures HWD/ED to check monthly. ED will review med cart audits at least quarterly.
January 10, 2024Complaint survey1 violation
Inspection dates
01/10/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/10/2024 10:25 am- 3:19 pm 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 1/2/2024 regarding allegations in the area(s) of: Staffing Number of residents present at the facility at the beginning of the inspection: 36 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: 17 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-1130-A
Based on the employee timesheets reviewed, the facility failed to ensure that when 20 or fewer residents are present in the safe secure unit that at least two direct care staff members were awake and on duty at all times in the special care unit.
Evidence
  1. The staff schedule and employee timesheets provided by Staff #1 to licensing inspector for 1/1/2024 documented the facility’s safe, secure, unit had one staff member working from 7am- 3 pm shift.
Plan of correction
Steps to correct the noncompliance with the standard: HWD/ED to be notified of any schedule changes. If schedule coverage is not obtained, HWD/ED to cover Measures to prevent the noncompliance from occurring again: Staff training on callouts/schedule changes done on 1/24/24. Review of prn team members. Person(s) responsible for implementation of each step and/or monitoring preventative measures Charge nurse to notify HWD/ED timely of changes. HWD/ED to spot check schedule and spot checks of each shift to ensure schedule compliance
January 10, 2024Complaint survey5 violations
Inspection dates
01/10/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/10/2024 10:25 am -3:19 pm 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 1/2/2024 regarding allegations in the area(s) of: Resident Care and Related Services Buildings and Grounds The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Additional Comments/Discussion: All resident records were not available for licensing inspectors to review during the inspection. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the (allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the (complaint(s) 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-1180-A
Based on observation and staff interview, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision.
Evidence
  1. During a inspection of the memory care unit, Licensing Inspectors observed Spic and Span by the kitchen sink unattended in an open area accessible to the residents.
  2. During the inspection of the resident rooms in the memory care unit, Licensing Inspectors observed personal hygiene items (shampoo, lotion, razors, wound cleaner, tooth paste, cologne, perineum wash, hand sanitizer, body spray, barrier ointment, cleaning foam, deodorant, shaving cream, and mouthwash), unattended in the resident rooms (19-A, 18-A, 16-A, 15-A, 14-A, 13-A, 12-A, 9-A, 8-A, 10-A).
  3. The outside courtyard fencing has sharp nails that are exposed.
  4. Licensing Inspector observed a metal garden trowel accessible to residents.
Plan of correction
Steps to correct the noncompliance with the standard: All rooms checked, any cleaning items were removed, personal care items placed in lock box under sinks in each bathroom. Meeting held with family members about safety and Memory care Fencing replaced with 8’ vinyl fencing Measures to prevent the noncompliance from occurring again: Weekly checks of rooms by MCD. ED to spot check. Care staff to monitor and report any problems to MCD Person(s) responsible for implementation of each step and/or monitoring preventative measures MCD to check weekly, ED to spot check. BOM/ED to review with families prior to move in and as needed. MCD/ESD to check courtyard weekly
22VAC40-73-390-A
Based upon documentation review, the facility failed to ensure at or prior to the time of admission, there shall be a written agreement signed by the resident or legal representative.
Evidence
  1. Resident #2’s record provided to Licensing Inspector at the time of inspection, did not contain a signed resident agreement.
Plan of correction
Not published by VDSS.
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
  1. On 1/10/2024 during a tour of the facility, various resident’s rooms were observed with large areas of vinyl flooring which was peeling and in disrepair (19-A, 14-A, 17-B).
  2. The threshold is missing the transition strip from the bedroom to the shared bathroom (17A).
  3. The bathroom vent was hanging shared bathroom for room 16 A.
  4. The bathroom shower curtain had brown stains, shared bathroom for room 16 A.
  5. The supply closet in memory care unit had mold along the floorboard.
  6. Resident rooms were dusty, including ceiling fans, windowsills, and furniture.
  7. The walls in the resident bathrooms walls had holes.
  8. The walls in several resident bathrooms had a brown substance near the toilets and the toilet plunger.
  9. The vent registers in multiple resident bathrooms were rusty.
  10. The bathroom vanity floor had water damage and are peeling and deteriorating.
  11. Carpet was stained 11-A.
  12. The hallway door (near rooms 5B and 4B) which leads to the outside has a gap and cold air was coming through. There was a towel stuffed in the gap.
  13. Dead roaches were observed under the bathroom vanity (shared bathroom for room 17-A)
  14. The resident rooms were observed to have dusty ceiling fans 19-A
  15. Multiple resident bedroom and bathrooms had lightbulbs that were burned out.
  16. The kitchen cabinets in the memory care unit are in disrepair, there is a wooden board supporting the upper-level cabinets, the locking mechanism on the cabinets and drawers do not work therefore the residents have access to potentially harmful items such as cleaning supplies and nutritional supplement.
Plan of correction
Not published by VDSS.
22VAC40-73-560-F
Based upon, the staff interviews and contact, the facility failed to ensure that all records shall be made available for inspection by the department's representative.
Evidence
  1. During the January 10, 2024, complaint visit, the facility failed to have the resident and staff records available for inspection by the department’s representative.
  2. Staff #2 stated Resident records were locked in the former Health and Wellness Director’s office and there was no spare key available.
Plan of correction
Not published by VDSS.
22VAC40-73-870-B
Based on smell and staff interviewed, the facility failed to ensure the building was well-ventilated and free from foul, stale, and musty odors.
Evidence
  1. On 1/10/2024 during a tour of the facility, the room 11A had a strong smell of urine.
Plan of correction
Not published by VDSS.
April 25, 2023Inspection15 violations
Inspection dates
04/25/2023, 05/11/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/11/2023 from 8:19am – 4:14 pm and 5/11/2023 from 7:45 am – 9:20 am 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: 40 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Licensing Inspector observed a meal, inspected the facility and conducted resident interviews. 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. T he 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 Alyshia E. Walker, Licensing Inspector at (757)670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-260-A
Based on a review of staff records the facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment.
Evidence
  1. The employee file for Staff #3 (D.O.H) 12/20/2022 did not contain evidence of the staff member having First Aid certification.
Plan of correction
Not published by VDSS.
22VAC40-80-120-E-2
Based on observation, the center failed to post the findings of the most recent inspection of the facility.
Evidence
  1. During an inspection of the facility with Staff #1 on 5/11/2023, the findings of the most recent inspection of the center were not posted.
  2. Staff #1 acknowledged the most recent inspection findings were not posted.
Plan of correction
Steps to correct the noncompliance with the standard: State Inspection Binder put back in lobby on credenza. Measures to prevent the noncompliance from occurring again: Binders were packed up, due to remodel. Current and previous inspections kept in binder in lobby. ED to ensure that if binder needs to be moved that it will remain easily accessible and going forward could be kept in another accessible area. Person(s) responsible for implementation of each step and/or monitoring preventative measures ED and BOM to ensure binder is out during daily walk through to ensure compliance.
22VAC40-73-440-B
Based on record reviewed, the facility failed to ensure that uniform assessment instrument (UAI) forms were approved and signed by the administrator or the administrator's designee.
Evidence
  1. The UAI dated 4/14/2023 for Resident #3 and the UAI dated 1/1/2023 for Resident #4 did not contain an assessor signature and signature of the administrator or administrator designee.
Plan of correction
Steps to correct the noncompliance with the standard: ED corrected on site Measures to prevent the noncompliance from occurring again: HWD to review UAI with ED once completed. HWD to maintain tickler system. ED will review all UAI’s before filing. ED to review tickler monthly. Person(s) responsible for implementation of each step and/or monitoring preventative measures HWD to ensure all completed UAI’s reviewed with ED ED to review all UAI’s and review tickler system
22VAC40-73-870-A
Based on observations made during the tour of the building, the facility failed to have the interior and exterior of the building maintained in good repair and kept clean and free of rubbish.
Evidence
  1. The interior door which leads from the dining area to the courtyard does not latch and lock. During the inspection, the inspector was able to push the door open even when the locking mechanism was engaged.
  2. Staff #5 acknowledged the door was not working properly.
Plan of correction
Steps to correct the noncompliance with the standard: Employee contacted and copy of first aid card received. Measures to prevent the noncompliance from occurring again: HWD/BOM to utilize new hire checklist to ensure all documentation received. HWD/ED to schedule first aid certification as needed in house for renewals and new hires. HWD to utilize tickler system to ensure timelines are being met. Person(s) responsible for implementation of each step and/or monitoring preventative measures. HWD and/or ED to utilize tickler to ensure compliance of new team members and any renewals. HWD and/or BOM to utilize new hire checklist to ensure documents are obtained as applicable.
22VAC40-73-380-B
Based on record reviewed and staff interviewed, the facility failed to ensure the personal and social information document was kept current.
Evidence
  1. Resident #1’s personal and social information data form did not include the resident’s allergies.
  2. Resident # 3’s personal and social information data form did not include the resident’s date of admission.
  3. Resident # 4’s personal and social information data form did not include the resident’s allergies.
Plan of correction
Steps to correct the noncompliance with the standard: Social Data forms updated by hand to fill in any missing information. Measures to prevent the noncompliance from occurring again: ALIS face sheets to be updated with VA specific requirements. In the meantime, all social data forms will be updated on state form and kept current until the update in ALIS takes place. HWD to audit all charts to ensure compliance. BOM will ensure completion on admission by utilizing move in checklist. Person(s) responsible for implementation of each step and/or monitoring preventative measures HWD/ED to audit all charts to ensure social data sheet is completed fully. BOM to utilize move in checklist to ensure completion upon move in. ED to spot check monthly
22VAC40-73-450-E
Based on resident record reviewed, the facility failed to have the Individualized Service Plan (ISP) signed by the resident or his/her legal representative.
Evidence
  1. The ISP dated 1/21/2023 for Resident #1, the ISP dated 8/10/2021 for Resident # 5, and the ISP for Resident # 6 with identified need effective 1/10/2023 (ISP did not contain date of facility representative signed), did not contain resident or representative signatures.
Plan of correction
Steps to correct the noncompliance with the standard: HWD scheduled meetings with families and or residents to obtain signature. HWD to review with ED UAI and ISP. Measures to prevent noncompliance from occurring again: HWD to use tickler to ensure family meetings are scheduled each month when care plans are due to be updated and with change of condition. If POA is unable to be present, HWD to document that it was reviewed over phone if applicable, HWD to email care plan to POA and attach copy of email. Person(s) responsible for implementation of each step and/or monitoring preventative measures HWD to utilize tickler to ensure care plan meetings are completed timely. HWD will ensure signature is obtained or have documented as listed above. ED to review tickler each month and spot check ISP’s for compliance
22VAC40-73-450-F
Based on records reviewed and staff interviewed, the facility failed to ensure individualized service plan (ISP) shall be reviewed at least every 12 months and as needed as the condition of the resident changes.
Evidence
  1. Resident # 3 is receiving hospice services which are not documented on the ISP.
  2. The UAI dated 1/12/2023 for Resident # 4 assesses the resident as not needing assistance in wheeling however the resident’s ISP states the resident does not perform the act as he is confined to a bed/chair and unable to ambulate.
Plan of correction
Steps to correct the noncompliance with the standard: Authorization for approval of Special care unit obtained from POA Measures to prevent the noncompliance from occurring again: HWD and/or BOM will utilize move in checklist to ensure documentation received and signed prior to admission to MC. MCD and HWD to audit MC files to ensure compliance Person(s) responsible for implementation of each step and/or monitoring preventative measures. BOM or designee to obtain prior to admission. MCD/HWD to review with each admission. ED to spot audit for compliance.
22VAC40-73-610-B
Based on observations made during the tour of the facility on 4/25/2023 and 5/11/2023, the facility failed to have the menu for the current week posted.
Evidence
  1. During the time of the on-site inspection on 4/25/2023 there was no menu posted.
Plan of correction
Steps to correct the noncompliance with the standard: Menu posted in main dining room Measures to prevent the noncompliance from occurring again: Menu board was removed due to remodel. DSD and/or designee will ensure menus are printed and hung each week. Person(s) responsible for implementation of each step and/or monitoring preventative measures DSD to print and hang weekly ED and/or BOM to check during daily walk through
22VAC40-73-1110-A
Based on record reviewed and staff interviewed, the facility failed to ensure that prior to admitting a resident within a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator or designee shall determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident’s file.
Evidence
  1. The record for Resident #1 did not contain documented evidence of the licensee, administrator, or designee’s justification for the decision to place the resident in the safe, secure environment.
Plan of correction
Steps to correct the noncompliance with the standard: ED corrected on site Measures to prevent the noncompliance from occurring again: HWD to review all MC charts to ensure safe/secure environment documentation is filled out completely and in each MC chart. BOM and/or HWD to utilize move in checklist to ensure all documentation is received and a tickler system will be used for updates. Person(s) responsible for implementation of each step and/or monitoring preventative measures. HWD to ensure all charts are compliant. BOM/HWD to utilize checklist and tickler system. ED will spot audit to ensure compliance
22VAC40-73-1100-A
Based on resident record review, the facility failed to ensure that prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval of one of the following persons, in the following order of priority: The resident, if capable of making an informed decision; a guardian or other legal representative for the resident if one has been appointed; a relative who is willing to take responsibility to act at the resident’s representative; an independent physician who is skilled and knowledgeable in the diagnosis and treatment of dementia.
Evidence
  1. The record for Resident #2 did not contain prior written approval from the resident or their guardian or representative before the resident was placed in the safe secure environment.
Plan of correction
Steps to correct the noncompliance with the standard: Authorization for approval of Special care unit obtained from POA Measures to prevent the noncompliance from occurring again: HWD and/or BOM will utilize move in checklist to ensure documentation received and signed prior to admission to MC. MCD and HWD to audit MC files to ensure compliance Person(s) responsible for implementation of each step and/or monitoring preventative measures. BOM or designee to obtain prior to admission. MCD/HWD to review with each admission. ED to spot audit for compliance.
22VAC40-73-880-B
Based on observation, the facility failed to ensure a temperature of at least 72 degrees Fahrenheit was maintained in all areas used by residents during hours when residents are normally awake.
Evidence
  1. During the on-site inspection on 5/11/23 at 8:14 am, the room temperature in the dining area of the facility was 66 degrees.
Plan of correction
Steps to correct the noncompliance with the standard: Thermostat reprogrammed to 72 degrees. ESD to order locked to cover to go around the thermostat in dining room. Measures to prevent the noncompliance from occurring again: ESD and/or ED to check thermostats during daily walkthrough and spot check. Team training scheduled for 7/17/2023 Person(s) responsible for implementation of each step and/or monitoring preventative measures ESD and/or ED to check daily. Charge nurse to check thermostat each shift.
22VAC40-73-410-A
Based on records reviewed and staff interviewed, the facility failed to ensure upon admission, it would provide an orientation for new residents and their legal representatives.
Evidence
  1. Resident #6 was admitted to the facility on 1/7/2023 and the resident did not receive orientation until 1/19/2023.
  2. Staff #1 acknowledged the resident did not receive orientation upon admission as evident by the orientation documentation.
Plan of correction
Steps to correct the noncompliance with the standard: BOM to audit all files to ensure compliance Measures to prevent the noncompliance from occurring again: BOM to utilize a move in checklist to ensure orientation is completed on admission. Person(s) responsible for implementation of each step and/or monitoring preventative measures. BOM to utilize move in checklist to ensure all documentations are reviewed and complete. ED to review move in checklist and ensure compliance.
22VAC40-73-310-H
Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without a treatment plan.
Evidence
  1. Resident # 4 was prescribed Celexa 20mg 1 tablet daily. There was no psychotropic treatment plan in the resident file at the time of inspection.
Plan of correction
Steps to correct the noncompliance with the standard: Nurse contacted MD and obtained Psychotropic treatment plan. Measures to prevent the noncompliance from occurring again: HWD to train charge nurses on required treatment plans. Charge nurse to request a new/updated form with any medication changes. HWD to audit, then spot check monthly to ensure compliance. Person(s) responsible for implementation of each step and/or monitoring preventative measures.HWD set up training on 7/26/2023 with charge nurses. HWD to audit and review monthly for compliance. ED will spot check
22VAC40-73-50-B
Based on review of resident record, the facility failed to ensure that each record contain a written disclosure which contains all of the requirements of Standard 22VAC40-73-50 and that the disclosure be signed by the resident or by his legal representative.
Evidence
  1. The Disclosure for Residents #1 and # 3 were blank of the required elements in Standard 22VAC40-73-50 and there were no resident or legal representative signatures.
Plan of correction
Steps to correct the noncompliance with the standard: POA/Resident contacted and Disclosure completed. Measures to prevent the noncompliance from occurring again: BOM to utilize a move in checklist to ensure disclosure is completed. BOM to complete a file audit to ensure compliance. BOM to start tickler system to ensure annual review of disclosures are also compliant. Person(s) responsible for implementation of each step and/or monitoring preventative measures BOM will utilize checklist ED and/or HWD to do final review prior to new move in. ED to perform random audit monthly to spot check.
22VAC40-73-290-B
Based on observation, the facility failed to ensure the posting of the name of the current on-site person in charge.
Evidence
  1. During the on-site inspection on 4/25/23 and 5/11/23, the easel that contained the on-site person in charge was inaccurate.
Plan of correction
Steps to correct the noncompliance with the standard: LED and/or MOD to update easel board every am to show who the designated charge person is for that day. Measures to prevent the noncompliance from occurring again: LED and/or MOD to ensure compliance daily Person(s) responsible for implementation of each step and/or monitoring preventative measures. LED will be responsible for daily upkeep of easel board. ED and/or MOD to observe compliance during daily walkthrough.
April 25, 2023Complaint survey1 violation
Inspection dates
04/25/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Other/self-report/complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/25/2023 8:19am- 4:14pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 3/1/2023 regarding allegations in the area(s) of: Resident Care and Related Services 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at (757) 670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-460-D
Based on documentation and record review, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises.
Evidence
  1. On 3/1/2023 at 4:40pm two residents of the safe, secure, environment were able to walk out of the facility and walk down the road to the neighborhood behind the facility.
  2. Staff #1 acknowledged the residents eloped from the facility through a side exit during renovations of the unit.
Plan of correction
Steps to correct the noncompliance with the standard: Remodel completed, door alarms were checked and reset. Hourly head counts Measures to prevent the noncompliance from occurring again: Charge nurse to check door alarms each shift. ESD will ensure compliance by checking doors/alarms weekly. ED and HWD to spot check. Hourly rounds to continue by caregivers. All team members to assist in programming to keep residents engaged. Elopement Drill conducted to review with team. Training on elopement and prevention 3/3/2023 Person(s) responsible for implementation of each step and/or monitoring preventative measures ESD will check alarms weekly and ED to spot check.
June 13, 2022Inspection7 violations
Inspection dates
06/13/2022, 06/17/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Renewal Date(s) of inspection the licensing inspector was on-site at the facility for each day of the inspection: 6/13/22 & 6/17/22 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. Number of resident records reviewed: 5 Number of staff records reviewed: 7 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing Inspectors observed activities, meals and medication passes during the inspection. Additional Comments/Discussion: n/a 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.
Violations
22VAC40-73-610-B
Based on observations made during the on-site inspection on 6/17/22, the facility failed to document the menu substitutions on the posted menu.
Evidence
  1. During the on-site inspection on 6/17/22, the posted menu listed green salad, battered fried fish or roast beef, onion roasted potatoes, Normandy blend, baked roll. Meat balls, spinach, macaroni and cheese, and a roll were observed on each resident’s plate. The change was not made on the posted menu.
Plan of correction
Steps to correct the noncompliance with the standard: FSD will train dietary team on any substitutions and/or changes to menu be updated accordingly and reflected on posted menu Measures to prevent the noncompliance from occurring again: FSD to have all dietary team members trained on procedure Person(s) responsible for implementation of each step and/or monitoring preventative measures FSD to monitor posted menu each week to ensure any updates were noted. ED and/or BOM to spot check
22VAC40-73-610-B
Based on observations made during the inspection of the facility, the facility failed to have the menu for the current week posted.
Evidence
  1. During the on-site inspection on 6/13/22, there was no posted menu in a place conspicuous to residents.
  2. Staff # 8 acknowledged there was no weekly menu posted.
Plan of correction
Steps to correct the noncompliance with the standard: FSD posted current weekly menu in both AL and MC. Measures to prevent the noncompliance from occurring again: FSD to print and post menu each week on AL and MC. FSD to ensure menu is printed so that another dietary team member can access and post if FSD is not in community. Person(s) responsible for implementation of each step and/or monitoring preventative measures FSD will keep binder of upcoming weekly menus for easy access. FSD will ensure menu is kept current and posted. ED and BOM to spot check for compliance
22VAC40-73-290-B
Based on observation, the facility failed to ensure the posting of the name of the current on-site person in charge.
Evidence
  1. During the on-site inspection on 6/13/22, the easel that contained the on-site person in charge was blank. Later during the inspection, the LI observed Staff # 7 updating the easel.
Plan of correction
Steps to correct the noncompliance with the standard: Staff in charge will be posted daily on easel in front lobby. Corrected on site Measures to prevent the noncompliance from occurring again: 1:1 training with night shift person in charge conducted to ensure updates are done. Person(s) responsible for implementation of each step and/or monitoring preventative measures Night charge team member to update easel nightly, LED and/or MOD to check daily to ensure accuracy
22VAC40-73-40-B-4
Based on observation and interview with staff, the facility failed to ensure certain documents related to the terms of the license were posted on the premises of the licensed facility, including the most recently issued findings of the most recent inspection of the facility.
Evidence
  1. During the on-site inspection on 6/13/22, the most recent findings from the inspection dated 5/17/21 were not posted.
Plan of correction
Steps to correct the noncompliance with the standard: Current inspection along with last inspection put back in foyer. ED to that inspection remains in place and remains current. ED to also keep in binder in main lobby as a backup. Corrected on site Measures to prevent the noncompliance from occurring again: BOM and ED will check monthly to ensure inspection remains posted and current. Person(s) responsible for implementation of each step and/or monitoring preventative measures ED and BOM will check monthly and ongoing.
22VAC40-73-680-I
Based on documentation review, the facility failed to include all required documentation on the Medication Administration Record (MAR).
Evidence
  1. Resident # 3 had a physician’s order for Acetaminophen 500 mg. Take 2 tablets (1000mg) by mouth three times daily for pain. The medication administration spaces for the following dates and times were blank and there was no documentation on the back of the MAR: 5/7/22 3pm, 11pm 5/8/22 3pm , 11pm 5/27/22 3pm, 11pm 5/28/22 7am, 3pm, 11pm 5/29/22 7am, 3pm, 11pm 5/30/22 3pm 5/31/22 3pm, 11pm
  2. Resident #3 had a physician’s order for Biotin 1000 mcg. One tablet by mouth every day for supplement. The medication administration spaces for the following dates and times were blank and there was no documentation on the back of the MAR: 5/28/22 8am 5/29/22 8am
  3. Resident #3 had a physician’s order for Eliquis 2.5 mg. One tablet by mouth twice daily for prevention of blood clot. The medication administration spaces for the following dates and times were blank and there was no documentation on the back of the MAR: 5/28/22 7am, 8pm 5/29/22 7am, 8pm 5/31/22 8pm
  4. Resident #3 had a physician’s order for Levothyroxine Sodium 75mg tablet. One table to be given by mouth every day for hypothyroidism. The medication administration spaces for the following dates and times were blank and there was no documentation on the back of the MAR: 5/28/22 7am 5/29/22 7am
  5. Resident #4 had a physician’s order for Acetaminophen 500 mg. Two tablets (1000 mg) by mouth three times daily for osteoarthritis. The medication administration spaces for the following dates and times were blank and there was no documentation on the back of the MAR: 5/12/22 4pm 5/31/22 4pm
  6. Resident #4 had a physician’s order for Trazadone 50 mg. One tablet by mouth 2 times a day for behavioral disorders associated with dementia. The medication administration spaces for the following dates and times were blank and there was no documentation on the back of the MAR: 5/12/22 4pm 5/31/22 4pm
Plan of correction
Steps to correct the noncompliance with the standard: HWD to train and review all LPN and RMA’s on new ALIS system and will review proper documentation. Measures to prevent the noncompliance from occurring again: HWD will randomly spot check MAR weekly. HWD and audit MAR’s on a monthly basis to ensure compliance Person(s) responsible for implementation of each step and/or monitoring preventative measures HWD will have trainings completed with team by 7/30/2022. HWD to review weekly and as needed. ED to review periodically for upkeep.
22VAC40-73-260-C
Based on staff interview and observation the facility failed to have a listing of all staff who have current certification in First Aid and CPR posted in the facility readily available to staff.
Evidence
  1. During the on-site inspection on 6/13/22, there was not a posting of staff members who had current certification in First Aid and CPR.
Plan of correction
Steps to correct the noncompliance with the standard: CPR/First aid spreadsheet is will be posted and available. Corrected on site Measures to prevent the noncompliance from occurring again: HWD will set up training and keep spreadsheet current Person(s) responsible for implementation of each step and/or monitoring preventative measures HWD and/or ED will conduct audit. HWD to spot check to ensure spreadsheet remains posted.
22VAC40-73-870-A
Based on observation and interview, the facility failed to maintain the interior and exterior of the building in good repair.
Evidence
  1. During a tour of the facility on 6/13/22, the following areas were observed to be in need of repair:
  2. There were exposed wires from an alarm system in the main hallway on the memory care unit.
  3. The vinyl floor was peeling in a bedroom on the memory care unit.
  4. Staff # 8 acknowledged items listed above were in need of repair.
Plan of correction
Steps to correct the noncompliance with the standard: 1. ESD repaired alarm system wires 6/13/22 corrected on site 2. Flooring in room 12 on memory care has been replaced. Measures to prevent the noncompliance from occurring again: ESD will correct or contact contracted outside company for any repairs, daily walk through of community to oversee upkeep. Person(s) responsible for implementation of each step and/or monitoring preventative measures ESD to ensure daily walk throughs are conducted ED to ensure daily walkthrough by ESD and another management team member take place daily, any findings to be discussed in stand up and to ensure follow up has been completed
May 6, 2021Inspection5 violations
Inspection dates
May 6, 2021 , May 7, 2021 and May 17, 2021
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
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 monitoring inspection was initiated on 5-6-21 and concluded on date 5-17--21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was thirty-two. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three staff records, three resident records, staff schedule, health and fire inspection, fire drills and health care oversight documents, sworn disclosure and criminal record history for new hires since last inspection, nutrition report and pharmacy report. 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
22VAC40-73-250-D
Based on record review and staff interview, the facility failed to ensure the risk assessment for staff was no older than 30 days.
Evidence
  1. On 5-7-21, staff #6’s risk assessment submitted was dated 11-9-20. Staff’s date of hire was documented as 12-10-20 and the first day of employment was 12-15-20.
  2. On 5-17-21, staff #1 acknowledged staff’s TB was greater than 30 days.
Plan of correction
Steps to correct the noncompliance with the standard Staff #6 had an updated TB risk assessment completed on 5/24/2021 TB risk assessment will be repeated if employees start day is delayed greater than 30 days Measures to prevent the noncompliance from occurring again BOM will audit team members hired in the last 90 days employee files to ensure that the TB risk assessment was completed within 30 days of hire. Business Office Manager will notify ED and DRC if employee start date exceeds 30 days Person(s) responsible for implementation of each step and/or monitoring preventative measures Business Office Manager Executive Director Director of Resident Care
22VAC40-73-450-C
Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for two of three residents.
Evidence
  1. de ce:
  2. On 5-7-21, resident #1’s uniformed assessment instrument (UAI) dated 3-17-21 documented bladder assessed as independent/ no assistance needed. The individualized service plan (ISP) dated 4-7-21 documented resident incontinent less than weekly and use of protective undergarments used and incontinent care provided. Mobility assessed as mechanical help/human help (Supervision). The ISP did not include mechanical help assessed. Behavior was assessed as appropriate on the UAI but the ISP on 4-23-21 documented resident wandered weekly or more.
  3. Resident #3’s physical examination dated 7-27-20 documented resident is legally blind. This information is not documented on the 4-30-21 ISP.
  4. On 5-17-21, staff #1and #2 acknowledged all of resident #1 and #3’s assessed needs were not included on the ISP.
Plan of correction
Steps to correct the noncompliance with the standard Resident #1’s UAI updated to show resident incontinent less than weekly, needs help with toileting. And behavior pattern updated to show that resident wandered weekly or more Resident 1’s ISP will be updated to mobility with supervision and walker. Resident #3’s ISP will be updated to include resident is legally blind Measures to prevent the noncompliance from occurring again ED will re-educate DRC to UAI manual to ensure all resident assessed needs are documented on the UAI and ISP ED will review UAIs and ISPs weekly for 3 months to ensure all needs assessed and documented on UAI and ISP. Person(s) responsible for implementation of each step and/or monitoring preventative measures Executive Director Director of Resident Care
22VAC40-73-650-B
Based on record review and staff interview, the facility failed to ensure the physician or other prescriber’s orders, both written and oral, for administration of all prescription and over-the-counter medications shall identify the diagnosis, condition, or specific indications for administering each drug.
Evidence
  1. 1 On 5-7-21, resident #3’s Lisinopril documented on the physician’s order dated 4-30-21, did not include the diagnosis, condition, or specific indications for the medication.
  2. On 5-17-21, staff #1 acknowledged, resident #3’s physician’s order for Lisinopril did not include a diagnosis, condition, or specific indications for the medication.
Plan of correction
Steps to correct the noncompliance with the standard Res #3 had the diagnosis or indication for use for Lisinopril clarified with the physician. The DRC/Designee will complete a 100% audit of all ordered medications to ensure diagnosis or indication for use is present Measures to prevent the noncompliance from occurring again Current LPNs and CMAs will be reeducated to the medication management plan, specifically on obtaining a diagnosis or indication for use for each medication when order given The DRC/designee will audit new physician orders 3 times a week for 4 weeks than weekly for 8 weeks to ensure each medication order has a diagnosis or indication for use. Person(s) responsible for implementation of each step and/or monitoring preventative measures Executive Director Director of Resident Care
22VAC40-73-680-K
Based on record review and staff interview, the facility failed to ensure the physicians or other prescriber’s order for use of PRN medications included the exact dosage for a medication administered by the medication aides.
Evidence
  1. On 5-7-21, resident #1’s physician’s order dated 5-5-21 prescribed Miralax as needed (PRN). The order documented ? 17 gm mixed with liquid of choice?“ The April 2021 medication administration record (MAR) documented, ”give 17 g of powder mixed with 4 to 8 oz. of water?.
  2. On 5-17-21, staff #1 acknowledged the PRN for Miralax did not include the exact dosage.
Plan of correction
Steps to correct the noncompliance with the standard Res. #1’s order for Miralax was clarified with the physician on 5/25/2021 to show the specific amount of fluid to administered DRC/designee will review all current residents with orders for Miralax to ensure that the order indicates the specific amount of fluid to be administered Measures to prevent the noncompliance from occurring again Current LPNs and CMAs will be reeducated to the medication management plan, specifically to the requirements for a complete order and to clarify and incomplete orders to inform physician’s that ranges are not permitted. The DRC/designee will audit new physician orders 3 times a week for 4 weeks than weekly for 8 weeks to ensure each medication order is complete. Person(s) responsible for implementation of each step and/or monitoring preventative measures Executive Director Director of Resident Care
22VAC40-90-40-B
Based on documents reviewed and staff interview, the facility failed to ensure the criminal history record report shall be obtained on or prior to the 30th day employment for each employee.
Plan of correction
Steps to correct the noncompliance with the standard Staff #6’s VA State Police Background check was obtained on 5/25/2021 Business Office Manager will audit current employee files to ensure facility in compliance with standards. Person(s) responsible for implementation of each step and/or monitoring preventative measures ED/ Business Office Manager