VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Dec. 28, 2021

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 GROUNDS 22VAC40-61 EMERGENCY PREPAREDNESS

Comments:

An unannounced renewal inspection was conducted on 12-28-2021 by two Licensing Inspectors from 9:17 a.m. until 1:57 p.m. Upon arrival, there were 18 participants in care with an additional of 26 scheduled to come throughout the day. Some participants were observed eating a morning snack of fruit and or eggs. Participants were also observed being engaged in volleyball during the inspection. Four participants and three staff records were reviewed. There were five new staff members hired since the last inspection. There was not any opportunities for medication administration observation to be observed. The menu, activity calendar, fire drill records, health and fire inspection, building and vehicle first aid kits, and water temperature were reviewed.

Violations:

Standard #:	22VAC40-61-460-H
Description:	Based on observation and discussion, the center failed to ensure hot water at taps available to participants are maintained within a temperature range of 105?F to 120?F. Evidence: 1. On 12-28-2021, during a tour of the center with Staff #1, three sinks were checked for the hot water temperature. One of the sinks in the women?s restroom only reached 93.9?F. 2. Staff #1 acknowledged the hot water was not within a temperature range of 105?F to 120?F.
Plan of Correction:	The water temperatures will be checked bi-weekly to ensure they are within the acceptable range of 105 degrees Fahrenheit to 120 degrees Fahrenheit.
Standard #:	22VAC40-61-460-I
Description:	Based on observation, the center failed to ensure disposable gloves are in each restroom at all times. Evidence: 1. On 12-28-2021, while conducting the inspection at the center, the single use restroom closest to the large dayroom was observed being utilized by participants and did not have disposable gloves available.
Plan of Correction:	A secured box will be installed in the restroom for disposable gloves.
Standard #:	22VAC40-61-530-B
Description:	Based on observation and discussion, the center failed to ensure a fire and emergency evacuation drawing showing primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers shall be posted in a conspicuous place. Evidence: 1. On 12-28-2021, during a tour of the center with Staff #1, the fire and emergency evacuation drawing posted did not include areas of refuge or assembly areas. 2. Staff #1 acknowledged the fire and emergency evacuation drawing posted in the center did not include these two areas.
Plan of Correction:	The areas of refuge and assembly areas will be added to the posted fire and emergency drawings.
Standard #:	22VAC40-61-540-E
Description:	Based on record review and discussion, the center failed to ensure the record of the required fire and emergency evacuation drills include all of the items as identified in the standard. Evidence: 1. On 12-28-2021, during an inspection of the center with Staff #1, the fire and emergency evacuation drills were reviewed. The drills held from July 2021-November 2021 did not document identify the person conducting the drill. 2. Staff #1 acknowledged the record of the required fire and emergency evacuation drills did not identify the person conducting the drill.
Plan of Correction:	The fire drill record was updated to include the name of the person conducting the fire drills for July 2021-November 2021. The identity will be documented for each monthly fire drill moving forward.
Standard #:	22VAC40-61-550-A
Description:	Based on observation and discussion, the center failed to ensure the buildings first aid kit include all of the items as identified in the standard. Evidence: 1. On 12-28-2021, during an inspection of the center with Staff #1, the first aid kit of the building and vehicle were reviewed. The building first aid kit did not include a disposable single-use breathing barriers or shields for use with breathing or CPR. 2. Staff #1 acknowledged the missing item from the building first aid kit.
Plan of Correction:	Disposable single-use breathing barriers will be included in the first aid kits.