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: May 16, 2024

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:

22VAC40-61-180

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/16/2024 from 9:35 am to 2:52 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: 28 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 5 Number of staff records reviewed: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 3 participants. The following were reviewed: participant and staff records, fire drills, medication cart, and the first aid kit. 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 #:	22VAC40-61-150-B
Description:	Based on record review, the center failed to ensure documentation of the type of training received, the entity that provided the training, number of hours of training, and dates of the training be kept by the center in a manner that allows for identification by individual staff person and is considered part of the staff member's record. Evidence: 1. The 2023 annual training for Staff #4 did not include the number of hours for the trainings received.
Plan of Correction:	Ensure at least 12 hours of annual training is completed and documented for each staff member.
Standard #:	22VAC40-61-160-A-1
Description:	Based on interview, the center failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #1 was unable to provide a current certification in first aid for Staff #2 and Staff #4 who work as direct care staff.
Plan of Correction:	Ensure all staff members have proof of first aid in their personnel file.
Standard #:	22VAC40-90-40-B
Description:	Based on interview, the center failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. Staff #1 was unable to provide a completed criminal history record report for Staff #6 (hired 03/12/2024).
Plan of Correction:	Ensure staff members have a criminal history record report on or prior to the 30th day of employment for each employee.