VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sentara PACE - Churchland
5788 Churchland Boulevard
Portsmouth, VA 23703
(757) 392-2650

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

Inspection Date: Jan. 10, 2023

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

Technical Assistance:

22VAC40-61-50 22VAC40-61-60 22VAC40-61-300

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: 01/10/2023 from 9:05 am to 3:12 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: 2 ? Census by end of day - 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 6 Number of staff records reviewed: 4 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 #:	22VAC40-61-300-A
Description:	Based on observation, record review, and interview, the center failed to implement the center?s medication management plan to include methods for monitoring medication administration and the effective use of the MARs for documentation. Evidence: 1. During a medication observation with Staff #3, the MAR indicated that there were two separate Bumetanide 1mg tablet orders for Participant #7. Staff #3 stated that one was a duplicate order. Staff #3 documented on the MAR that they only administered 1mg of Bumetanide to Participant #7 on 1/10/2023. 2. During a review of Participant #7?s orders and progress notes, documentation indicated that Participant #7?s provider prescribed a new order on 1/9/2023 for the participant to receive an additional 1mg dose of Bumetanide from 1/10/2023-1/13/2023. With the additional order prescribed for this three-day period, in addition to a scheduled 1mg dose of Bumetanide, Participant #7 should receive a total of 2mg Bumetanide. 3. Staff #2 acknowledged that the MAR indicates Participant #7 was administered only 1mg of Bumetanide on 1/10/2023.
Plan of Correction:	Administration nurse will be educated on medication documentation. Nurse will select each ordered medication indicated on the MAR. Clinical manager will audit medication administration documentation bi-weekly for accuracy for the next 60 days.
Standard #:	22VAC40-61-410-A
Description:	Based on observation and interview, the center failed to ensure the interior and exterior of all buildings be maintained in good repair, kept clean and free of rubbish, and free from safety hazards. Evidence: 1. During the inspection on 1/10/2023, the fence in the outdoor courtyard to the touch was not secure. 2. Staff #1 acknowledged the concern regarding the stability of the outdoor fence.
Plan of Correction:	A fence replacement quote is currently undergoing the internal approval process. Once approval has been obtained, the materials needed will be ordered and installed as soon as they arrive.
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. During the inspection on 1/10/2023, the two individual bathrooms in the large dayroom did not have disposable gloves available.
Plan of Correction:	22VAC40-61- 460-I Based on observation, the center failed to ensure disposable gloves are in each restroom at all times. Evidence: 1. During the inspection on 1/10/2023, the two individual bathrooms in the large dayroom did not have disposable gloves available. Gloves were removed from the bathrooms at the beginning of the pandemic, and aides began carrying them on their person. Gloves will be added back to the bathrooms.