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 27, 2022 and April 29, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/27/22 9:45am-3:30pm & 4/29/22 10:00am-11:30am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 4/12/22 regarding allegations in the area(s) of: STAFFING AND SUPERVISION, ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS, RESIDENT CARE AND RELATED SERVICES, AND RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS Number of residents present at the facility at the beginning of the inspection: 24 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Scheduled activities did not take place. Additional Comments/Discussion: The facility is in the process of hiring an activity director for the facility but currently shares the activity director with the skilled nursing department. An exit meeting was conducted to review the inspection findings.

Violations:

Standard #:	22VAC40-73-520-I
Complaint related:	Yes
Description:	Based on observations and an interview, the facility failed to ensure changes, substitutions were documented on the posted activities calendar. Evidence: 1. On April 27, 2022, during an inspection of the facility, two LIs observed the posted activities calendar which listed 11:30am Resident Council Meeting and 2:00pm Outside Fresh Air. No activities were held during these times. 2. On April 29, 2002, during an inspection of the facility the posted activities calendar listed 10:30am Move to The Beat Workout. This activity was not held but an unlisted Bingo activity was held at 11:00am. 3. Staff #1 and Staff #2 stated the activities were not held and the assisted living facility is in the process of hiring a new Activities Director. The assisted living facility currently shares the skilled nursing Activities Director.
Plan of Correction:	Correction All current activity calendars were removed from resident living areas. An updated activity calendar, to reflect changes with daily programming, for the month was posted and copies provided to all residents. Other Potential All residents who choose to participate in activities may have been impacted. A 100% audit was completed and all residents? calendars have been updated. System Change The facility policy for management of monthly activities calendar was reviewed and the unit charge was in serviced on 7/8/22 by the administrator. The policy and procedures for preparing and updating activity calendars as well as the requirement to conduct posted activities daily was reviewed with the unit charge. Residents/resident representatives were educated on their rights to receive accurate activities calendars and participate in posted activities of the day. Monitoring The administrator/designee will review, once weekly x4 weeks, activities conducted for that day to ensure activity posted on calendar matches activity provided to residents. Variances will be corrected as needed. Date ? July 11, 2022