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: April 22, 2021 and April 23, 2021

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 EMERGENCY PREPAREDNESS

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 04-22-2021 and concluded on 04-23-2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 19. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 2 resident records, 2 staff records, staff schedules, fire drills, fire and health inspection reports, and healthcare oversight. There were no new hires since the last renewal inspection. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review and interview, the facility failed to ensure the resident?s admission physical examination included the resident?s height, weight, and a description of reactions to any known allergies. Evidence: 1. Resident #2?s ?Report of Resident Physical Examination? dated 02-19-2021 did not include documentation of the resident?s height, weight, and description of the resident?s allergic reaction to Iodine. 2. Staff #1 acknowledged resident #2?s admission physical examination did not include the aforementioned required information.
Plan of Correction:	1. Resident #2?s Admission physical examination did not include resident height, weight and description of reaction to any known allergies. 2. Resident #2 admission physical examination has been completed to include resident height, weight, and description of reaction to any known allergies. 3. Program Director will audit all residents? chart to ensure they include resident height, weight, and description of reaction to any known allergies. 4. Program Director will review all new admissions chart to include resident height, weight, and description of reaction to any known allergies.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview, the facility failed to administer medications in accordance with the physician's instructions. Evidence: 1. Resident #2?s current signed physician?s order dated 02-22-2021 documented ?Calcium Citrate 250mg 1 tab PO [by mouth] BID [twice a day] for Supplement.? 2. Resident #2?s February 2021 and March 2021 Medication Administration Record documented staff administered 1 tab of Calcium Citrate 250mg once a day on 02-23-2021 through 03-04-2021. 3. Staff #1 and staff #2 acknowledged resident #2?s Calcium Citrate 250mg was not administered in accordance with the physician?s instructions.
Plan of Correction:	1. Resident #2?s medication ?Calcium Citrate 250mg? was not administered 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 4/12/2022 to ensure compliance. 4. Program Director will monitor all staff for accuracy to maintain compliance.