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: Oct. 1, 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 GENERAL PROVISIONS 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:

22VAC40-73-490 Health care oversight 22VAC40-73-990 Plan for resident emergencies and practice exercise

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: An unannounced renewal inspection took place on 10/01/2024 at 8:37 am to 2:09 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: 19 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 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 #:	22VAC40-73-250-D
Description:	Based on the onsite record review, the facility failed to ensure health information required by these standards shall be maintained at the facility and shall be included in the staff record for each staff person. Subsequent tuberculosis (TB) evaluations and reports. Evidence: 1. The record for staff #2, hire date 5/24/19 and 5/31/24, does not contain a current annual risk assessment for TB. The record for staff #2 contains a risk assessment for TB dated 2/07/2020.
Plan of Correction:	Staff #2, and all staff will have updated TB upon hire and annually. All current resident?s records will be audited by the Program Director and Administrator to include evidence of subsequent tuberculosis (tb) evaluations and reports with facility. The Program Director and Administrator will audit staff charts disclosure records every 6months and yearly to ensure compliance
Standard #:	22VAC40-73-450-A
Description:	Based on the record review the facility failed to ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Exception: A Preliminary plan of care is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission. Evidence: 1. The record for resident #1, admission date of 9/28/24, does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission. Resident?s #1 ISP is dated as completed on 9/30/24.
Plan of Correction:	All current residents will have a care plan completed within 7 days prior to admission for their health and safety, and welfare and to address their needs. The Program Director will ensure that a template is available for care plans and will audit charts 2 days prior to admission to ensure all documents are completed.
Standard #:	22VAC40-73-450-E
Description:	Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative. Evidence: 1. Resident?s #1 ISP dated 9/30/24 does not include the signature and date of the licensee, administrator, or his designee, and the resident or his legal representative. 2.. Resident?s #2 ISP dated 8/23/24 does not include the signature and date of the resident or his legal representative.
Plan of Correction:	All current residents have their ISP completed signed and dated by the resident. License, administrator, or his designee the resident or legal representative. The Program Director will ensure that all ISPs are signed and have a date of by the license, administrator, or his designee and the resident or his legal representative by doing a chart audited 2 days before admission to ensure the documents have been completed.
Standard #:	22VAC40-73-660-A
Description:	Based on observation the facility failed to ensure medications shall be stored in a manner consistent with current standards of practice. The storage area shall be locked. Evidence: 1. During the onsite inspection on, 10/01/24, the Licensing Inspector (LI) observed medications in a plastic bag in an unlocked office. 2. Staff #3 stated the medications located in the unlocked office room, were removed from the medication cart the day prior and the medications will be returned to the pharmacy.
Plan of Correction:	All medications are stored and locked in their proper location for the safety of the residents. All medication will be stored in a locked area until deposition of medication. The facility will dispose of medication in a timely manner to ensure the safety of residents. This will be checked by the Program Director and oversea by the administrator daily.
Standard #:	22VAC40-73-680-I
Description:	Based on the record review the facility failed to ensure the Medication Administration Record (MAR) should include: Any medication errors or omissions. Evidence: 1. Resident?s #2 MAR did not contain staff initials and/or reason for omissions on the following dates for the following medications: 9/17/24 for Loratadine, Metamucil, and Atorvastatin;
Plan of Correction:	Resident #2 had no adverse reaction effects from the practice. The facility failed to ensure the Medication Record should include medication errors or omissions by not contain staff initials or reason for not given medication for resident #2 staff was in-service that prior to end of shift to check (MAR) for missing signature and educated to always put reason for not given medication and report to program Director. The Program Director will check MAR every morning and run a report to reason why medications were not given and to ensure all (MAR) was signed to ensure compliance.