VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sentara Senior Community Care
5900 E. Virginia Beach Blvd. #260
Norfolk, VA 23502
(757) 252-7800

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: Dec. 5, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 ADMISSION, RETENTION AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUND 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

22VAC40-61-50-D

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: 12/05/2022 from 10:27 am to 3:30 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of participants present at the facility at the beginning of the inspection: 35 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 8 Number of staff records reviewed: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-61-180-E-2
Description:	Based on record review, the center failed to ensure all staff and volunteers have an annual tuberculosis risk assessment completed. Evidence: 1. On the day of inspection, Staff #1 could not provide documentation of a current annual evaluation for tuberculosis (TB) for Staff #5.
Plan of Correction:	Conduct annual tuberculosis risk assessment screenings on all staff and volunteers for the current year
Standard #:	22VAC40-61-230-D
Description:	Based on record review, the center failed to ensure the plan of care be developed to maximize the participant's level of functional ability and to support the principles of individuality, personal dignity, and freedom of choice. Evidence: 1. Participant #1?s assessment dated 8/31/2022 indicates the participant needs supervision with transferring and walking; however, the participant?s plan of care dated 8/31/2022 states the participant requires supervision and mechanical assistance with transferring and walking. 2. Participant #2?s assessment dated 6/10/2022 indicates the participant is incontinent weekly or more with bowel and wanders/passive weekly or more; however, the participant?s plan of care dated 11/30/2022 states the participant is incontinent of bowel less than weekly and displays normal behavior weekly or more. 3. Participant #3?s assessment dated 10/19/2022 indicates the participant needs mechanical and physical assistance with bathing and walking and wanders/passive weekly or more; however, the participant?s care plan dated 10/19/2022 states the participant requires physical assistance with no additional equipment for bathing, supervision with walking, and displays wandering behavior less than weekly. 4. Participant #5?s assessment dated 11/29/2022 indicates the participant is incontinent of bowel and bladder weekly or more, needs supervision with mobility, wheeling is not performed, and wanders/passive weekly or more; however, the participant?s care plan dated 11/25/2022 states the participant is incontinent of bowel and bladder less than weekly, requires supervision and mechanical assistance with mobility, needs physical assistance with wheeling, and displays wandering behavior less than weekly. 5. Participant #6?s care plan dated 10/27/2022 indicates the participant?s code status as DNR; however, the participant?s record did not include a DNR and reflected the participant as a Full Code. 6. Participant #7?s assessment dated 7/27/2022 indicates the participant needs supervision with mobility and wanders/passive less than weekly; however, the participant?s care plan dated 7/27/2022 states the participant requires no additional assistance with mobility and displays wandering behavior weekly or more.
Plan of Correction:	Homecare Team Coordinator will conduct a monthly audit to ensure the 99P and care plan matches. DON to ensure that audits are being conducted.
Standard #:	22VAC40-61-300-A
Description:	Based on observation and discussion, the center failed to implement procedures for administering medication per their medication management plan which includes methods to secure and maintain supplies of each participant's prescription medications and any over-the-counter drugs and supplements in a timely manner to avoid missed dosages. Evidence: 1. During a medication observation with Staff #2, the center did not have Amlodipine 5mg tablet available for administration to Participant #1. 2. Upon close of inspection on 12/5/2022, Staff #2 confirmed Participant #1 had left the center for the day and was not administered the medication as it was not available.
Plan of Correction:	The Clinic nurse will ensure that medications are ordered/refilled 7 days prior to medication running out. The clinic nurse will ensure all medications are available and administered prior to the participant departure from the center each day.