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: May 31, 2022

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

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: 05/31/2022 from 8:56 am to 1:06 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: 14 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 8 Number of staff records reviewed: 4 Observations by licensing inspector: A morning snack and activities were observed while on-site. 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-A
Description:	Based on record review and interview, the facility failed to ensure direct care staff attend at least 12 hours of training annually. Evidence: 1. During review of the training records while onsite 05-31-2022, Staff #1 could not provide documentation for annual training for Staff #5.
Plan of Correction:	Tracking document for education plan revised to include date and signature of when education was completed.
Standard #:	22VAC40-61-230-E
Description:	Based on record review, the facility failed to ensure the plan of care be reviewed and updated as significant changes occur and at least every six months. Evidence: 1. The plan of care for Participant #7 was not updated to reflect the DNR effective 4/12/22. The plan of care was completed on 3/2/22 and states the participant is a ?full code with no limits.?
Plan of Correction:	Social Work will update the plan of care when code status changes.
Standard #:	22VAC40-61-260-B
Description:	Based on record review, the center failed to obtain an evaluation by a qualified licensed practitioner that completes an assessment for tuberculosis (TB) in a communicable form no earlier than 30 days before admission. Evidence: 1. Participant #3 admitted on 4/1/2022; however, the tuberculosis risk assessment prior to admission for Participant #3 was completed on 2/12/2022.
Plan of Correction:	Education will be provided to the nursing staff on the requirements of having a PPD placed 30 days prior to admission into the PACE program. Clinical manager will review the Sentara PACE Tuberculosis screening form for all new admissions to ensure compliance.
Standard #:	22VAC40-61-360-B-1
Description:	Based on observation, the center failed to ensure menus for meals and snacks for the current week are dated and posted in an area conspicuous to participants. Evidence: 1. On 05-31-2022, during an inspection of the facility, the menu for meals and snacks for the current week was not observed to be posted in the center.
Plan of Correction:	The menus for meals will be posted at all times in an area conspicuous for all participants.
Standard #:	22VAC40-61-510-A
Description:	Based on record review, the center failed to comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: 1. The last inspection by the appropriate fire official was completed on 05-12-2021.
Plan of Correction:	The facility will contact the Fire Marshal for reinspection at least 15 days prior to due date for reinspection.