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Source: VA State Licensing Agency
Type of inspection: Renewal An unannounced mandated renewal inspection was conducted on 6-2-25 (Ar. 07:53 a.m./Dep 1:15 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: 58 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: 7 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, water temperature, emergency food, signaling check, breakfast meal. 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
Type of inspection: Monitoring An unannounced non-mandated monitoring inspection was conducted on 4-14-25. (Ar. 08:35 a.m./Dep 12:05 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: 62 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: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Medication pass observation, first aid kit check, water temperature and observation of breakfast 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
Based on document reviewed and staff interviewed, the facility failed to ensure the written assurance was provided to the resident that the facility has the appropriate license to meet the resident?s care needs at the time of admission. Evidence: 1. On 4-14-25, resident #3?s written assurance document did not include a date. The resident?s physician?s order dated 3-20-25 noted date of admit as 3-5-25. 2. Staff #1 acknowledged the resident?s written assurance document did not include a date.
Based on observation by staff and inspector, the facility?s hot water at taps available was not maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees Fahrenheit. Evidence: 1. On 4-14-25 during a tour of the facility with staff #2, the water temperature by the door in the men?s bathroom on the second floor had a temperature reading of 99.1 degrees F. 2. The water temperature at the sink in the shower/tub room on the first floor across from room #104 had a reading of 101 F. The bathtub reading in the same room had a temperature reading of 94.8 F. 3. Staff #2 acknowledged the water temperatures in the bathrooms were not within a range of 105 degrees F to 120 degrees F.
Based on document reviewed and staff interviewed, the facility failed to ensure acknowledgment of having received the orientation was signed and dated by the resident, as appropriated, resident?s legal representative. Evidence: 1. On 4-14-25, resident #3?s orientation document to the facility did not include date orientation was signed and did not include signature of resident?s legal representative. 2. Staff #1 acknowledged the resident?s orientation document did not include the date of acknowledgment of the orientation to the facility.
Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without appropriate diagnosis and treatment plans for a resident. Evidence: 1. On 4-14-25, resident #2?s physician?s order dated 2-27-25 and April 2025 medication administration record ( MAR
Type of inspection: Monitoring An on-site non-mandated monitoring was conducted on 2-24-25 (Ar: 07:05/ Dep 12:40 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: 59 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: 6 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; breakfast meal, first aid kit check, water temperature check; 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. 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
Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without appropriate diagnosis and treatment plans for two of six records. Evidence: 1. On 2-24-25, resident #4?s physician?s order dated February 2025 medication administration record ( MAR
Based on observation, the facility failed to ensure the interior of the building was maintained in good repair. Evidence: 1. On 2-24-25, during a tour of the facility with staff #2, the wallpaper on the wall on the first floor, back hallway was observed peeling from the baseboard area of the wall. 2. The female bathroom on the second floor, first toilet stall?s pilaster and pilaster shoe were observed to be crumbling and in need of repair. 3. Staff #2 acknowledged the bathroom?s stall/pilaster base was in need of repair.
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan ( ISP
Type of inspection: Monitoring An on-site unannounced non-mandated monitoring was conducted on 12-12-24. (Ar 07:35 a.m./Dep 12:25 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: 62 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: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast-lunch-activity with church-medication pass 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
Based on record reviewed and staff interviewed, the facility failed to ensure the preliminary plan of care include what services staff were to provide for the residents. Evidence: 1. On 12-12-24, resident #1?s uniformed assessment instrument ( UAI
Based on observations and interviews during a tour of the facility, residents? rooms did not have pillows on the bed. There were rooms that did not have enough chairs for the number of residents assigned to the room. Evidence: 1. On 12-12-24 during a tour of the facility with staff #2, rooms #208, #209, #216 and #201 had four residents assigned and three chairs in the room. 2. Rooms #205 and #214 was missing pillows from two beds in each room. 3. Room #210 missing pillowcases from pillows on bed. 4. There was no toilet paper in the stall near the window in male bathroom with tub upstairs. 5. Staff #2 acknowledged the rooms did not have all required resident accommodations, chairs and/or pillows and pillowcases.
Type of inspection: Monitoring An on-site non-mandated monitoring inspection was conducted on 10-15-24 (Ar 07:38 a.m/ Dep 13:20 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: 62 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: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: breakfast meal, water temperature, first aid kit 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
Based on record reviewed and staff interviewed, the facility failed to ensure that the resident?s individualized service plan ( ISP
Based on observation, record reviewed, and staff interviewed, the facility failed to ensure medications ordered for PRN
Based on record reviewed and staff interviewed, the facility failed to ensure when medication aides administer the PRN
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: 1. On 10-15-24 during a tour of the facility with staff #2, the water temperature at the faucet in the bathtub in the tub room on the first floor near the laundry room at 12:40 p.m. was 91.9. 2. Staff #2 acknowledged the water temperature in the tub room on the first floor was not within the required range.
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. Evidence: 1. On 10-15-24, resident #4?s October 2024 medication administration record ( MAR
Type of inspection: Monitoring An unannounced non-mandated monitoring inspection was conducted on 8-5/24 with two inspectors from the Peninsula Licensing Office. AR 07:20/Dep 12:05. Facility census was 61. The administrator was not present. Preliminary exit conducted with administrator via telephone conference with inspectors, staff person in charge and administrator. 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: 61 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: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: AC unit not working, ventilation extension through window upon arrival. 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
Based on record reviewed and staff interviewed, the facility failed to ensure the documented interview between the administrator or a designee responsible for admission and retention decisions, the individual and or legal representative, if applicable was in the resident?s record and included the mental health screening. Evidence: 1. On 8-5-24, resident #4?s record included a copy of the interview and mental health screening document; however, the documents did not include a date and there was no name of the documents. 2. Staff #2 acknowledged the mental health and interview document in the resident?s record did not include signatures, dates or names.
Based on observation and staff and residents interviewed, the facility failed to ensure the air conditioning (AC) system for all areas used by residents, including residents? bedrooms and common areas that the temperatures in these areas did not exceed 80 degrees Fahrenheit (F). Evidence: 1. On 8-5-24, during a tour of the facility, the temperature in the common area/dining area was measured using a moveable thermometer and the reading was 83 to 85 degrees F. The temperature in resident room #202 was 87.3 F. The reading in the upstairs hallway to the right of the elevator was 87 degrees. The reading in the residents? room #213 was 87.6 This room was observed with two long aluminum-colored ducts in the windows and connected to a cooling system in the hallway. The ducts prevented the bedroom door from being closed, thereby preventing the residents from having privacy in their bedroom. 2. The Accu Weather for Newport News noted temperature of 92 degrees on 8/2/24; 90 degrees on 8/3/24; 85 degrees on 8/4/24 and 87 degrees on 8/5/24. 3. Staff #2 acknowledged the temperature in the facility exceeded 80 degrees F in areas utilized by the residents.
Based on observation and staff interviewed, the facility failed to ensure it maintain a written work scheduled that included the names and job classification of all staff working each shift with an indication of whomever is in charge at any given time. Evidence: 1. On 8-5-24, the staff scheduled posted with the names of staff on duty and staff in charge was dated July 21, 2024, to August 3, 2024. 2. Staff #2 acknowledged the posted schedule for staff and administrator was not current.
Based on interview and observation, 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, safety or welfare of any resident. Evidence: 1. On 8-5-24, upon entering the facility, the inspectors inquired of staff #2 the reason for the aluminum-colored ducts observed hanging on the outside of the building and the windows opened on the second floor. Staff stated the facility?s air conditioning system was not working. Staff was asked when this occurred, and it was stated the past Friday, (August 2nd). 2. The facility?s AC system not working was not reported to the licensing department. 3. Staff #1 acknowledged the AC system not working was not reported to the licensing office.
Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without appropriate diagnosis and treatment plans. Evidence: 1. On 8-5-24, resident #6?s July 2024 medication administration record ( MAR
Based on record reviewed and staff interviewed, the facility failed to ensure health information required by the standards was conducted within the required timeframe. Evidence: 1. On 8-5-24, staff #3?s record noted staff?s date of hire as 7-10-2023. The tuberculosis (TB) screening in the record was dated 8-18-23, not on or within seven days prior to the first day of work at the facility. 2. Staff acknowledged staff?s TB was not within the required timeframe.
Based on record reviewed the facility failed to ensure the rights and responsibilities of residents in assisted living facility was reviewed with staff. Evidence:. 1.Staff #5?s date of hire noted as 6-20-24. The record did not have documentation of a signed and dated copy of the resident?s rights. 2. Staff #2 acknowledged the staff member records did not include signed and dated initial or annual resident?s right review.
Based on record reviewed, the facility failed to ensure the individualized service plan reviewed and updated included all assessed needs. Evidence: 1. On 8-5-24, resident #3?s application dated 1-13-23 noted allergy to strawberry. The resident?s physician order dated 7-26-24 also noted resident?s allergy to strawberry and Ascorbic acid. These assessed needs were not documented on the resident?s individualized service plan ( ISP
Based on record reviewed and staff interviewed, the facility failed to ensure upon review of the UAI
Based on record reviewed and staff interviewed, the facility failed to ensure the orientation and training required for staff occurred within the first seven working days of employment. Evidence: 1. On 8-5-24, staff #5?s orientation and training documents (including job description, organizational chart) did not include the date the training and documents were received/reviewed by staff. 2. Staff #2 acknowledged the staff?s documents did not include a date of receipt.
Type of inspection: Renewal An unannounced renewal inspection was conducted on 6-12-24 with two licensing inspectors from the Peninsula Licensing Office. Ar 07:45 a.m./Dep 13:15 p.m.) The facility census was 54. 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: 54 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: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Medication pass/ breakfast meal Additional Comments/Discussion: psychotropic medication/ infection control policy 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
Based on record reviewed and staff interviewed, the facility failed to ensure that the resident?s individualized service plan ( ISP
Based on record reviewed and staff interviewed, the facility failed to ensure that it had a physical examination for a resident within 30 days preceding the resident?s admission. Evidence: 1. On 6-12-24, resident #5?s record noted the resident?s physical examination was dated 12-4-23. The resident?s date of admission to the facility was noted as 9-14-23. 2. Staff #1 acknowledged the resident physical was completed 12-4-23, after the resident?s admission date.
Based on document reviewed and staff interviewed, the facility failed to ensure all physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall include, the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often the medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. On 6-12-24, resident # 1?s physician?s orders sheet (POS) dated 4-11-24 did not include a diagnosis for Ibuprofen. 2. Resident #3?s physician?s telephone order signed and dated 4-26-24 did not include a diagnosis for Mobic and HCTZ. The physician order dated 4-26-24 did not include a diagnosis for Quetiapine Fumarate. 3. Staff #1 acknowledged; the resident?s physician?s orders did not include the diagnosis for the prescribed medication.
Based on document reviewed and staff interviewed, the facility failed to ensure subsequent tuberculosis (TB) evaluation and reports were completed for one of three staff records reviewed. Evidence: 1. On 6-12-24, staff #1?s tuberculosis assessment was dated 5-4-23. The staff?s date of hire noted as 8-25-20. 2. Staff #1 acknowledged the tuberculosis assessment was not current.
Based on observation and staff interviewed, the facility failed to ensure the bed linen for a resident was clean. Evidence: 1. On 6-12-24, during a tour of the facility with staff #1, the box spring cover on a resident?s bed in room #211 was observed with have light grey- and orange-colored stains. 2. Staff #1 acknowledged the box spring cover was not clean.
Based on observations and staff interviewed, the facility failed to ensure that 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: 1. On 6-12-24 during a tour of the facility with staff #1, the front sink near a stall, had a slow drain. The male restroom in the common area was observed with a slow drain. The window blind in room #211 was observed to have an approximate 8 x 8-inch cutout section. The window blind in the far-right corner in room #209 was in need of repair. The commode top in the corner bathroom down the hall from the kitchen and next to the storage room, extended beyond the commode (did not fit). 2. Staff #1 acknowledged the building and equipment items needed repair.
Based on observation and staff interviewed, the facility failed to ensure that staff followed the facility?s policies and procedures for hand hygiene. Evidence: 1. On 6-12-24 during the medication pass observation with staff #2, staff was observed using the facility?s hand sanitizer. The hand sanitizer was dated 6-2023. Staff #2 stated not knowing that hand sanitizers had an expiration date. 2. Staff #1 was informed of the expiration date on the bottle of the hand sanitizer used by staff #1 during the medication pass. Staff #1 stated the staff should be washing hands between medication pass in accordance with the facility?s policies and procedures. 3. The facility policies and procedures documented handwashing and the use of hand sanitizer. 4. The hand sanitizer used by the facility during the medication pass noted an expiration date of 6-2023. 5. Staff #1 and #2 acknowledged the hand sanitizer was expired.
Based on observation and staff interviewed, the facility failed to ensure that single-use and dedicated medical supplies and equipment shall be appropriately labeled and stored. Evidence: 1. On 6-12-24, during the medication pass observation with staff #2, resident #7?s blood sugar glucometer was observed to not be labeled. 2. Staff #2 acknowledged the resident?s blood sugar glucometer was not labeled.
Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s annual/reassessed individualized service plan ( ISP
Based on documents reviewed and staff interviewed, the facility failed to ensure the facility?s medication administration record ( MAR
Type of inspection: Complaint An unannounced complaint inspection was conducted on 2-14-24; Ar 09:30 a.m./ dep 11:55 a.m. The facility census was 64. 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 1-24-24 regarding allegations in the health safety and welfare and resident care. Number of residents present at the facility at the beginning of the inspection: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: 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
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