VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Nans Pointe Rehabilitation and Nursing LLC
200 West Constance Road
Suffolk, VA 23434

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: June 26, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Technical Assistance:

Resident Rights Posting

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: An unannounced monitoring inspection took place on 06/26/24 at 8:38 am to 3:10 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: 17 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: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: An observation of breakfast was completed. A medication pass observation was completed with 2 residents. A review of the facility?s staffing schedule was completed. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at (757) 353-0430 or by email at Donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on the onsite record review the facility failed to ensure the assisted living facility shall prepare and provide a statement to the prospective resident and his legal representation. The statement shall disclose the following information which shall be kept current: The name of the facility; the name of the licensee. Evidence: 1. Residents #1, #2, #3, #4, #5, and #6 disclosure statements did not include the name of the facility and the name of the licensee. 2. Staff #2 confirmed the disclosure statements for residents #1, #2, #3, #4, #5, and #6 did not include the new name of the facility and the licensee. 3. A change in ownership for the facility occurred on 05/01/24. The facility was notified on 04/02/24 via email to update the disclosure statement for all residents to include the new name of the facility and licensee effective 05/01/24.
Plan of Correction:	1. Facility failed to disclose their disclosure statements that include the new name of facility for resident #1, #2, #3, #4, #5 and#6 currently reside in the facility currently and have no adverse effects. 2. Residents #1, #2, #3, #4, #5 and#6 statements will be updated to include the new name of the facility. 3. All current resident?s records will be audited by the Program Director and Administrator to include evidence of statement disclosures with facility new name. 4. The Program Director and Administrator will audit residents? disclosure statements records yearly to ensure compliance. 5. Date of Compliance 7/15/24.
Standard #:	22VAC40-73-310-D
Description:	Based upon review of the UAI prior to admission of a resident, the assisted living facility administrator shall provide written assurance to the resident that the facility has the appropriate license to meet his care needs at the time of admission. Copies of the written assurance shall be given to the legal representative and case manager, if any, and a copy signed by the resident or his legal representative shall be kept in the resident?s record. Evidence: 1. The record for resident #1, admission date 05/08/2024, did not contain a written assurance the facility has the appropriate license to meet his or her care needs at the time of admission.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-A
Description:	Based on the record review the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following as listed in the subsection. Evidence: 1. The record for resident #1, admission date 05/08/24, did not contain documentation of a physical examination completed within 30 days preceding admission. 2. Staff #2 confirmed the record for resident #1 did not contain documentation of a physician exam completed within 30 days prior to the resident?s admission date.
Plan of Correction:	1. Facility failed to disclose a written physically within 30 days prior to the resident admission resident #1, #2, currently reside in the facility and currently have no adverse effects. 2. Facility will have a physical completed 30 days prior to residents? admission. 3. All current resident?s records will be audited by the Program Director and Administrator to include evidence of a physical completed 30 days prior to residents? admission 4. The Program Director and Administrator will audit residents? charts upon admission and annually . 5. Date of Compliance 7/15/24.
Standard #:	22VAC40-73-390-A
Description:	Based on the record review the facility failed to ensure at or prior to the time of admission, there shall be a written agreement/acknowledgement of notification dated and signed by the resident or applicant for admission or the appropriate legal representative, and by the licensee or administrator. Evidence: 1. Resident?s #1 admission agreement dated 05/08/24 did not include the licensee or administrator?s signature.
Plan of Correction:	1. Facility failed to ensure at or prior to the time of admission an agreement/acknowledgement of notification dated and signed by the resident or applicant for admission or the appropriate legal representative, and by the licensee or administrator for resident #1 currently reside in the facility currently and have no adverse effects. 2. Residents #1 admission an agreement/acknowledgement will be signed and dated by the resident or applicant for admission or the appropriate legal representative, and by the licensee or administrator on admission or prior. 3. All current residents? records will be audited by the Program Director and Administrator charts upon admission and annually. 4.The Program Director and Administrator will audit residents? admission agreement /acknowledgement records yearly to ensure compliance. 5.Date of Compliance 7/15/24.
Standard #:	22VAC40-73-390-C
Description:	Based on the record review the facility failed to ensure the original agreement/ acknowledgement shall be updated whenever there are changes to any of the policies or information referenced or identified in the agreement/acknowledgement and dated and signed by the licensee or administrator and the resident or his legal representative. Evidence: 1. Resident?s #2 original agreement dated 10/14/23 was not updated to reflect the new name of the facility and licensee for the change in ownership effective 05/01/24. 2. Resident?s #3 original agreement dated 03/16/24 was not updated to reflect the new name of the facility and licensee for the change in ownership effective 05/01/24. 3. Resident?s #4 original agreement dated 04/01/24 was not updated to reflect the new name of the facility and licensee for the change in ownership effective 05/01/24. 4. Resident?s #5 original agreement dated 2/24/22 was not updated to reflect the new name of the facility and licensee for the change in ownership effective 05/01/24. 5. Resident?s #6 original agreement dated 01/09/23 was not updated to reflect the new name of the facility and licensee for the change in ownership effective 05/01/24. 6. A change in ownership for the facility occurred on 05/01/24. The facility was notified via email on 04/02/24 to provide a new resident agreement to all residents when the new license became effective 05/01/24.
Plan of Correction:	1. Facility failed to ensure originally admission an agreement/acknowledgement admission was updated whenever there are changes to any of the policies or information referenced or identified in the agreement/acknowledgement dated and signed by the resident or applicant for admission or the appropriate legal representative, and by the licensee or administrator for resident #1,#2,#3,#4,#5 and #6 currently reside in the facility currently and have no adverse effects. 2. Residents #1, #2, #3, #4, #5 and #6 admission an agreement/acknowledgement will be signed and dated by the resident or applicant for admission or the appropriate legal representative, and by the licensee or administrator will be updated whenever changes occur. 3. All current residents? records will be audited by the Program Director and Administrator charts annually and upon name change. 4.The Program Director and Administrator will audit residents? admission agreement /acknowledgement records yearly to ensure compliance. 5.Date of Compliance 7/15/24.
Standard #:	22VAC40-73-410-A
Description:	Based on the record review the facility failed to ensure upon admission, the assisted living facility shall provide an orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of the call system. Acknowledgement of receiving the orientation shall be signed and dated by the resident and, as appropriate his legal guardian, and such documentation shall be kept in the resident?s record. Evidence: 1. The record for resident #1, admission date 05/08/24, did not contain documentation the facility provided an orientation to the resident and/ or their legal guardian. 2. Resident?s #2, #3, #4, #5, and #6 resided at the facility prior to the change in ownership eff. 05/01/24. The residents? records did not include documentation the facility provided an orientation to the resident and/ or their legal guardian. 3. A change in ownership for the facility occurred on 05/01/24. The facility was notified via email on 04/02/24 to provide an orientation for all residents when the new license became effective 05/01/24. 4. Staff #2 confirmed the records for residents #1, #2, #3, #4, #5, and #6 did not contain documentation the facility provided an orientation to the residents.
Plan of Correction:	1. Facility failed to ensure upon admission, the assisted living facility orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of call bell system signed and dated by the resident or legal guardian and kept in the resident?s records for resident #1. Addition residents #2, #3, #4, #5 and#6 to included current name change on orientation. Currently reside in the facility and have no adverse effects. 2. Residents #1, #2, #3, #4, #5 and#6 facility orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of call bell system will be signed and dated by the resident or legal guardian and kept in the resident?s records with new name of the facility. 3. All current resident?s records will be audited by the Program Director and Administrator to include evidence of facility orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of call bell system will be signed and dated by the resident or legal guardian with facility new name. 4. The Program Director and Administrator will audit residents? records yearly to ensure compliance. 5. Date of Compliance 7/15/24.
Standard #:	22VAC40-73-640-A
Description:	Based on the record review and staff interview the facility failed to ensure the facility shall implement a written plan for medication management to include methods to ensure each resident?s prescription medication and any over the counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: 1. During the medication pass observation on 06/26/24 with staff #4, the following medication was not located and available to administer to resident # 4: Physician order dated 04/12/24 ?Magnesium Oxide-Supplement 400 (240mg) take 0.5 tablet by mouth once daily for anemia.? 2. Resident?s #4 medication administration record (MAR) documents on 06/24/24 the resident?s Magnesium Oxide Supplement was exhausted and re-ordered on 06/24/24.
Plan of Correction:	1. Facility failed to ensure the facility shall implement a written plan for medication management to include methods to ensure each resident has prescription medication and over the counter drugs and supplements ordered for refill and are filled in a timely manner to avoid missed dosages by staff #4, currently reside in the facility currently and have no adverse effects. 2. Residents #4 Magnesium Oxide were not given according to physician?s orders. 3. All staff were in service following physician?s orders for proper medication administration and ordering medications within the last 7 days of doses. 4. Program Director or designee will perform random medication pass weekly for 4 weeks. 5.The Program Director will monitor all staff for accuracy to maintain compliance. 6.Date of Compliance 7/15/24.