VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Accordius Health at Nans AL LLC
200 West Constance Road
Suffolk, VA 23434
(757) 539-8744

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Feb. 10, 2020

Complaint Related: No

Areas Reviewed:

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

An unannounced monitoring inspection was conducted on 02-10-2020 from 7:13 AM to 2:24 PM. There were 20 residents in care at the time of the inspection. A tour of the facility was conducted and water temperatures were sampled. The emergency food and water supply was observed. A medication pass observation was conducted. LI observed lunch and an activity during the inspection. Interviews were conducted. The following documents were reviewed: resident and staff records, criminal background checks and sworn disclosures for newly hired staff, health care and dietary oversight, resident council, fire and emergency evacuation drills, emergency preparedness plan, menus, activity calendars and first aid kit. The following was discussed with the Assisted Living Director and Administrator: resident agreements, disclosure statements, staff orientation, medication administration, physician's orders, staff TB screenings, and UAI/ISP's. The facility received violations "under" Administration and Administrative Services, Personnel, Admission, Retention, and Discharge of Residents, and Resident Care and Related Services. The areas of noncompliance were discussed with the Assisted Living Director throughout the inspection and during the exit interview. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the Violation Notice within 10 days of today's date, 03-07-2020.

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on record review and interview, the facility failed to disclose whether or not the facility has an onsite emergency electrical power source for the provision of electricity during an interruption of the normal electric power supply. If the facility does have an onsite emergency electrical power source, the statement must include: (i) the items for which the source will supply power and (ii) whether or not staff of the facility have been trained to maintain and operate the power source; as well as a notation that additional information about the facility that is included in the resident agreement is available upon request. Evidence: 1. During resident record review with staff #1, resident #1?s disclosure statement dated 01-09-2020, and resident #2?s disclosure statement dated 01-02-2020 did not include documentation of whether or not the facility has an onsite emergency electrical power source for the provision of electricity during an interruption of the normal electric power supply or a notation that additional information about the facility that is included in the resident agreement is available upon request. 2. During interview, staff #1 acknowledged the facility did not disclose the aforementioned required information on resident #1 and resident #2?s disclosure statement.
Plan of Correction:	1. Facility failed to disclose evidence of on-site emergency electrical power source for the provision of electricity in event of power failure for resident #1 and #2 disclosure statement. 2. Residents? #1 and #2 disclosure statement will be updated to include evidence of on-site emergency electrical power source for the provision of electricity in event of power failure. 3. All current residents? records were audited by the Program Director to include evidence of on-site emergency electrical power source for the provision of electricity in event of power failure. 4. Program Director or the designee will audit residents? disclosure statements records bi-weekly x 4, monthly x3 all to ensure compliance.
Standard #:	22VAC40-73-120-B
Description:	Based on record review and interview, the facility failed to ensure all staff are oriented to the facility's organizational structure; daily routines; the facility's policies and procedures; specific duties and responsibilities of their positions; and required compliance with regulations for assisted living facilities as it relates to their duties and responsibilities. Evidence: 1. During staff record review with staff #1, staff #2 and staff #3?s ?New Hire Orientation? was not dated and did not include the facility's organizational structure; daily routines; the facility's policies and procedures; specific duties and responsibilities of their positions; and required compliance with regulations for assisted living facilities as it relates to their duties and responsibilities. Staff #1 could not locate and/or provide additional documentation of the staff being oriented to the aforementioned information. 2. During interview, staff #1 acknowledged the staff did not receive the required orientation.
Plan of Correction:	1. Facility failed to ensure staff #1, #2, and #3 have required orientation, or training on staff files. 2. All staff files will be audited to ensure required orientation, or training and personal and social data are maintained on staff files. 3. Facility Program Director was in-serviced to ensure all staff orientation, or training and personal and social data are maintained on staff files. 4. Program Director or the designee will audit monthly x 6 months then yearly, all staff personnel file to ensure compliance.
Standard #:	22VAC40-73-250-D
Description:	Based on record review and interview, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility submitted the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment should be no older than 30 days. Evidence: 1. During staff #2?s record review with staff #1, staff #2 (hired on 12-23-2019) did not have documentation of a tuberculosis risk assessment on file. 2. During staff #3?s record review with staff #1, staff #3 was hired on 01-23-2020. The tuberculosis risk assessment on file dated 05-21-2019 was older than 30 days from the date of hire. 3. Staff #1 could not locate and/or provide documentation of an additional risk assessment, documenting the absence of tuberculosis in a communicable form within 30 days of the date of hire for staff #2 or staff #3. 4. During interview, staff #1 acknowledged the facility did not submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form on or within seven days prior to the first day of work for staff #2. Staff #1 acknowledged staff #3?s tuberculosis risk assessment was older than 30 days.
Plan of Correction:	1. Facility failed to ensure staff #1, #2, and #3 have required documentation of Tuberculosis risk assessment on employee files. 2. All staff files will be audited to ensure required screening forms were maintained on employees? files. 3. Facility Program Director was in-serviced to ensure upon hire, all employees have screening requirements on their files. 4. Program Director or the designee will audit employees? files monthly x 6 months then yearly, all staff personnel file to ensure compliance.
Standard #:	22VAC40-73-390-A
Description:	Based on record review and interview, the facility failed to ensure the resident written agreement/acknowledgment included the required information. Evidence: 1. During resident record review with staff #1 and staff #2, resident #1?s ?Resident Agreement? dated 01-24-2020, and resident #2?s ?Resident Agreement? dated 01-09-2020 did not include the following required information: a. Rules relating to nonpayment. b. The amount and purpose of an advance payment or deposit payment and the refund policy for such payment. c. The refund policy to apply when transfer of ownership, closing of facility, or resident transfer or discharge occurs. d. Requirements or rules to be imposed regarding resident conduct. e. The policies regarding the amount of notice required when a resident wishes to move from the facility; pets living in the facility; weapons; visiting in the facility; the administration and storage of medications and dietary supplements; whether or not the facility maintains liability insurance that provides at least the minimum amount of coverage established by the board for disclosure. f. The resident or his legal representative or responsible individual as stipulated in 22 VAC 40-73-550 H has reviewed ? 63.2-1808 of the Code of Virginia, Rights and Responsibilities of Residents of Assisted Living Facilities, and that the provisions of this statute have been explained to him; the resident or his legal representative or responsible individual as stipulated in 22VAC40-73-550 H has reviewed and had explained to him the facility's policies and procedures for implementing ? 63.2-1808 of the Code of Virginia g. The resident has been informed of the following: he may refuse release of information regarding his personal affairs and records to any individual outside the facility, except as otherwise provided in law and except in case of his transfer to another caregiving facility, notwithstanding any requirements of this chapter; residents may establish and maintain a resident council, that the facility is responsible for providing assistance with the formation and maintenance of the council, whether or not such a council currently exists in the facility, and the general purpose of a resident council; the bed hold policy in case of temporary transfer or movement from the facility, if the facility has such a policy. h. The rules and restrictions regarding smoking on the premises of the facility. 2. During interview, staff #1 and staff #2 acknowledged the facility?s resident written agreement/acknowledgment did not include the required information.
Plan of Correction:	1. Facility failed to ensure the written agreement/acknowledgement of notification for admission for residents? #1 and #2 includes rules relating to nonpayment, rules and restrictions regarding smoking on the premises of the facility. 2. Residents? #1 and #2 record has been updated with signed written agreement/acknowledgement of notification for admission to include rules relating to nonpayment, rules and restrictions regarding smoking on the premises of the facility. 3. All current residents? records were audited by the Program Director to ensure no other incidents occurred, and no other incident noted. 4. Facility Program Director was in-serviced by the Executive Director to ensure that all potential resident(s) have in their records signed written agreement/acknowledgement of notification for admission that includes rules relating to nonpayment, rules and restrictions regarding smoking on the premises of the facility. 5. Program Director or the designee will audit residents? records bi-weekly x 4, monthly x3 all to ensure compliance.
Standard #:	22VAC40-73-390-C
Description:	Based on record review and interview, the facility failed to ensure the original resident agreement/acknowledgment was updated whenever there are changes to any of the information referenced or identified in the agreement/acknowledgment and dated and signed by the licensee or administrator and the resident or his legal representative. Evidence: 1. During resident record review with staff #1, resident #1 admitted to the facility on 01-24-2020 and resident #2 admitted to the facility on 01-09-2020. Resident #1?s ?Resident Agreement? dated 01-24-2020, and resident #2?s ?Resident Agreement? dated 01-09-2020 documented ?The private pay rate is $121/D First 30 days, $141/D Month 2,3, and 4, $151/D Thereafter? for room and board. a. Resident #1?s billing statement dated 02-10-2020 documented the resident was charged a room and board rate of $151.00/D for the period of 01-24-20 - 01-31-20, and 02-01-20 - 02-29-20. b. Resident #2?s billing statement dated 01-24-2020 documented the resident was charged a room and board rate of $151.00/D for the period of 01-09-20 - 01-31-20, and 02-01-20 - 02-29-20. c. Resident #1 and resident #2 were not billed $121/D for the first 30 days, or $141/D for the 2nd month per the original ?Resident Agreement.? 2. The facility did not have documentation on file of an updated agreement/acknowledgement dated and signed by the licensee or administrator and the resident or his legal representative regarding the aforementioned changes to the private pay rates for room and board for resident #1 or resident #2. 3. During interview, staff #1 acknowledged resident #1 and resident #2?s billing statement did not reflect the agreed upon charges per the ?Resident Agreement.?
Plan of Correction:	1. Facility failed to ensure the original written resident agreement/acknowledgement of notification for admission for residents? #1 and #2 was updated whenever there are changes made to initial agreement/acknowledgement dated and signed by the licensee or administrator. 2. Residents? #1 and #2 admission agreement/acknowledgement has been updated with changes made on their initial signed written agreement/acknowledgement of notification for admission by the Administrator. 3. All current residents? records were audited by the Program Director to ensure no other incidents occurred, and no other incident noted. 4. Facility Program Director was in-serviced by the Executive Director to ensure that all potential resident(s) have updated changes made to their initial agreement/acknowledgement of notification for admission by the Administrator. 5. Program Director or the designee will audit residents? records bi-weekly x 4, monthly x3 all to ensure compliance.
Standard #:	22VAC40-73-680-B
Description:	Based on observation, record review, and interview, the facility failed to ensure medications are removed from the pharmacy container and administered to the resident by the same staff person. Evidence: 1. Resident #3?s current physician?s order dated 09-20-2019 documented ?Fluticasone 50mcg- Instill 1 spray into each nostril once daily.? The order did not document that the resident could self-administer the Fluticasone 50mcg nasal spray. 2. At approximately 7:28 AM, during the medication pass observation, staff #2 gave resident #3 the Fluticasone 50mcg nasal spray to administer to self. The resident was observed administering 2 sprays per nostril instead of 1 spray. 3. During interview, staff #1 and staff #2 acknowledged the Fluticasone 50mcg nasal spray was not administered by staff #2, and that resident #2 did not have an order to self-administer the medication.
Plan of Correction:	1. Resident #3 Fluticasone was not given according to Physician?s order. 2. All staff were in-serviced on following Physician?s order for proper Medication administration. 3. Program Director or designee will perform random medication pass weekly x 4, monthly x 4, quarterly then annually starting 03/22/2021 to ensure compliance. 4. Program Director will monitor all staff for accuracy to maintain compliance.
Standard #:	22VAC40-73-680-C
Description:	Based on observation, record review, and interview, the facility failed to ensure medications are administered no earlier than one hour before and no later than one hour after the facility's standard dosing schedule. Evidence: 1. Resident #2's February 2020 Medication Administration Record documented the following medications are scheduled to be administered at 9:00 AM: Prednisone 5mg, Cetirizine 10mg, Fluticasone 50mcg, Foltanx cap, Mycophenolic 180mg, Oseltamivir 30mg, and Sevelamer 800mg. 2. At approximately 7:28 AM, during the medication pass observation, staff #2 was observed administering the aforementioned scheduled 9:00 AM medications to resident #2. Resident #2?s medications were not administered within the facility?s standard dosing schedule. 2. During interview, staff #1 and staff #2 acknowledged resident #2?s medications were not administered within the facility?s standard dosing schedule.
Plan of Correction:	1. Resident #2 medication was given prior to the policy of no earlier than 1 hour before or no later than 1 hour after the facility?s standard dosing schedule. 2. All staff in-serviced on Medication administration policy; within the time frame of 1 hour before and no later than 1 hour after designated time on the Medication Administration Record unless medication is ordered for specific times such as before, after or with meals. 3. Program Director or designee will perform random medication pass weekly x 4, monthly x 4, quarterly then annually starting 03/22/2021 to ensure compliance. 4. Program Director will monitor all staff for accuracy to maintain compliance.
Standard #:	22VAC40-73-680-D
Description:	Based on observation, record review, and interview, the facility failed to ensure medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. Resident #2?s February 2020 Administration Record (MAR) and physician?s order dated 07-20-2019 documented Prednisone 5mg- 3 tabs one time daily. 2. At approximately 7:28 AM, during the medication pass observation, staff #2 was observed placing 1 tablet of Prednisone 5mg into the pill cup. Prior to staff #2 placing resident #2?s medications back into the medication cart, the Licensing Inspector informed staff #2 that only 1 tablet of Prednisone 5mg was placed into the pill cup, instead of 3 tablets per the MAR. 3. Staff #2 acknowledged there was only 1 tablet of Prednisone 5mg in the pill cup, instead of 3 tablets per the physician?s order.
Plan of Correction:	1. Resident #2 Prednisone were not given according to Physician?s orders. 2. All staff were in-serviced on following Physician?s orders for proper Medication administration. 3. Program Director or designee will perform random medication pass weekly x 4, monthly x 4, quarterly then annually starting 03/22/2021 to ensure compliance. 4. Program Director will monitor all staff for accuracy to maintain compliance.
Standard #:	22VAC40-73-680-E
Description:	Based on record review and interview, the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber are provided according to his instructions and documented. The documentation should be maintained in the resident's record. Evidence: 1. During resident #4?s record review with staff #1, the current physician?s order on file dated 12-08-2019 documented ?Weigh daily every day shift for Health Failure Monitoring Alert MD for weight gain of 3lbs in one day, 5 lbs in one week, increased Edema, SOB.? The January and February 2020 Medication Administration Record documented the resident had a weight gain over 3 lbs in one day on 01-28-2020 (258.4 lbs) to 01-29-2020 (264.2 lbs) and on 02-02-2020 (262.2lbs) to 02-03-2020 (266 lbs). There was no documentation on file verifying the physician was made aware of the residents weight gain on 01-29-2020 or 02-03-2020. 2. Staff #1 could not verify and/or provide documentation of the physician being notified of the resident #4?s weight gain. 3. During interview staff #1 acknowledged the facility did not notify the physician of the resident #4?s weight gain in accordance with the physician?s instructions.
Plan of Correction:	1. Facility failed to notify the physician of resident #4 weight gain in accordance with physician?s instruction. 2. All staff were in-serviced on following Physician?s orders, notifying physician of resident weight gain according to the physician instruction. 3. Program Director or designee will perform random audit of residents Medical Records (MAR) weekly x 4, monthly x 4, quarterly then annually starting 03/22/2021 to ensure compliance. 4. Program Director will monitor all staff for accuracy to maintain compliance.
Standard #:	22VAC40-73-680-G
Description:	Based on observation and interview, the facility failed to ensure over-the-counter medication was labeled with the resident's name. Evidence: 1. A bottle of Bayer Chewable Aspirin, PreserVision AREDS, and Tylenol were observed in medication ?B? cart with staff #2 present. The medications were not labeled with the resident?s name. 2. Staff #2 acknowledged the medications in the medication ?B? cart were not labeled with the resident?s name.
Plan of Correction:	1. Facility failed to ensure over-the-counter medication on the cart was labelled with resident?s name. 2. All staff were in-serviced on proper labelling of all medication with resident?s name. 3. All medication carts will be audited to ensure all medications were labeled properly. 4. Program Director or designee will perform random medication pass weekly x 4, monthly x 4, quarterly then annually starting 03/22/2021 to ensure compliance. 5. Program Director will monitor all staff for accuracy to maintain compliance.