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: March 11, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-61 PERSONNEL 22VAC40-61 ADMISSION, RETENTION, AND DISCHARGE 22VAC40-61 EMERGENCY PREPAREDNESS

Comments:

An unannounced monitoring inspection was conducted on 03-04-2022 from 9:30 a.m. until 1:57 p.m. Upon arrival, there were 24 participants in care with an additional of 23 scheduled to come throughout the day. Participants were observed being engaged in a craft led by two volunteers during the inspection. Six participants and three staff records were reviewed. There was one new staff member hired since the last inspection. There are no participants receiving medication at this time, therefore medication administration was not observed. The menu, activity calendar, fire drill records, health and fire inspection, building first aid kit, and water temperature were reviewed. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. The areas of noncompliance were discussed with the Director throughout the inspection and during the exit interview.

Violations:

Standard #:	22VAC40-61-160-A-1
Description:	Based on record review, the center failed 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 #2 is a Certified Nursing Assistant and was hired 05-15-2019; however, Staff #2 does not have a current certification in first aid.
Plan of Correction:	The center will conduct an audit of all direct care staff members to ensure current certification in first aid from the American Heart Association. The center will ensure all direct care staff members have up to date certifications in first aid from the American Heart Association.
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. Staff #2 did not have a current annual evaluation for tuberculosis (TB). The last TB evaluation for Staff #2 is 05-07-2019. 2. Staff #1 acknowledged the TB evaluation for Staff #2 is not current.
Plan of Correction:	The center will conduct annual tuberculosis risk assessment screenings on all staff and volunteers for 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 #3?s assessment dated 3/22/2021 indicates the participant needs mechanical and physical assistance with bathing; however, the participant?s plan of care dated 10/2/21 states the participant ?requires physical assistance and no additional equipment with bathing.? Participant #3?s assessment indicates the participant needs mechanical and supervision with toileting; however, the participant?s plan of care states the participant ?requires supervision and requires no additional equipment with toileting activities.? Additionally, the assessment for Participant #3 indicates the participant has bladder incontinence weekly or more; however, the plan of care indicates the participant has bladder incontinence less than weekly. 2. Participant #4?s assessment dated 1/28/2022 indicates the participant has bladder incontinence less than weekly; however, the participant?s plan of care dated 1/28/2022 states the participant has bladder incontinence weekly or more.
Plan of Correction:	Homecare Team Coordinator will conduct a monthly audit to ensure the assessment and care plan matches. DON to ensure that audits are being conducted.
Standard #:	22VAC40-61-550-A
Description:	Based on observation, the center failed to contain a first aid kit which shall include a list of items as identified in the standard. Evidence: 1. On 03-11-2022, first aid kit of the building was reviewed. The building first aid kit did not include bee sting swabs or preparation.
Plan of Correction:	First Aid Kits will be refilled with bee sting ointment.