VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Abundant Care Assisted Living
5556 Paca Lane
Va beach, VA 23462
(757) 519-9100

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

Inspection Date: March 22, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced renewal inspection was conducted by two Licensing Inspectors (LI) on 03-22-2022 from 8:36 AM to 11:32 AM. There were 6 residents in care at the time of the inspection. A tour of the facility was conducted, breakfast meal observed, medication cart inspected, and first aid kit reviewed. There have not been any new hires, admissions or discharges since the last inspection. LIs reviewed 3 staff records and 4 resident records. All morning medications were administered prior to start of inspection. 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 Administrator throughout the inspection and during the exit interview.

Violations:

Standard #:	22VAC40-73-200-D
Description:	Based on record review, the facility failed to obtain a copy of the certificate issued or other documentation indicating that a person in a role as direct care staff had met one of the requirements to work as direct care staff. Evidence: 1. Staff #4 was hired on 1/5/21 as direct care staff. The record for Staff #4 included a Nurse Aide license that expired 06/30/2019. There was no other documentation in Staff #4?s record indicating Staff #4 meets one of the requirements as direct care staff.
Plan of Correction:	Staff #4 change a position status due to lapse of her employment prior to coming back at Abundant Care. The certification of nurse aide is now on her employee record.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to 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 #4 works as direct care staff and does not have a current certification in first aid.
Plan of Correction:	Staff #4 is scheduled to take the earliest available date for 1st -Aid Training.
Standard #:	22VAC40-73-260-C
Description:	Based on observation and interview, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR be posted in the facility so that the information is readily available to all staff at all times. Evidence: 1. Staff #1 confirmed and acknowledged a listing of all staff who have current certification in first aid or CPR is not posted in the facility.
Plan of Correction:	The listing of all staff with current certification in first-aid and CPR has been posted.
Standard #:	22VAC40-73-325-B
Description:	Based on record review, the facility to ensure that a fall risk rating was completed for residents who meet the criteria for assisted living care at least annually, when the condition of the resident changes; and after a fall. Evidence: 1. Resident #2 met the criteria for assisted living care; however, there was no documentation of a current fall risk rating in the record.
Plan of Correction:	A fall risk rating document has been created for residents who meet the criteria for assisted living and will be implemented annually, when the condition of the resident changes, and after a fall.
Standard #:	22VAC40-73-610-D
Description:	Based on observation and interview, the facility failed to ensure when a diet is prescribed for a resident by their physician or other prescriber, it be prepared and served according to the physician's or other prescriber's orders. Evidence: 1. The staff preparing and serving food did not have documentation with all resident?s diets to ensure they are prepared and served according to the physician's or other prescriber's orders.
Plan of Correction:	A dietary menu prescribed by a registered dietician has been posted. It will be prepared and served according to the prescriber?s orders.
Standard #:	22VAC40-73-680-D
Description:	Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. Resident #1?s physician orders were reviewed by their physician and signed on 3/3/22. The orders indicate a change to Colace 100mg from one time daily to two times daily; however, the March 2022 MAR for Resident #1 does not reflect this change and the resident has continued to receive the medication one time daily. 2. Resident #4?s March signed physician order indicates a daily order for Miralax and a handwritten order for Miralax PRN. Upon review of the March 2022 MAR for Resident #4, the order for Miralax daily was discontinued and Miralax PRN was added. The signed physician order does not indicate the daily order for Miralax was discontinued. Staff #1 was not able to provide documentation that the order for daily administration of Miralax is discontinued.
Plan of Correction:	The record review of Resident #1 in question has been transcribed into the MAR in accordance with the prescriber?s instructions. Resident #4?s March signed physician order discrepancy has been secured and transcribed into the MAR in accordance with the prescriber?s instructions.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. Staff #4 was hired on 1/5/21 and does not have a completed criminal history record report.
Plan of Correction:	Staff #4 request of criminal record report has been requested.