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: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

Type of inspection: Renewal Date(s) of inspection the licensing inspector was on-site at the facility for each day of the inspection: 4/27/22 9:45am- 3:30pm and 4/29/22 10:00am- 11:30am 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: 5 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: Limited resident activities and residents not satisfied with the food. An exit meeting was 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.

Violations:

Standard #:	22VAC40-73-160-A
Description:	Based on record review, the facility failed to ensure the administrator attended at least 20 hours of training related to management or operation of a residential facility for adults or relevant to the population in care annually. Evidence: The Record of Staff Training provided for staff #1 documented 7 hours and 15 minutes of training.
Plan of Correction:	Correction The facility administrator will complete an additional 13 hours at minimum of relevant education related to management of a residential facility for adults or education relevant to the population in care. Other Potential All residents who reside in assisted living as well as all staff have the potential to be affected by a facility administrator that fails to complete relevant annual education. System Change The facility administrator was in serviced on 7/6/22 by the regional director of operations regarding the expectation to complete at minimum 20 hours of relevant education. Monitoring The business office manager will follow up with facility administrator to ensure 20 hours of annual education is completed and ensure documentation of completed hours is placed within administrator?s employee file. Variances will be corrected with notification to regional director of operations as needed. Date ? July 11, 2022
Standard #:	22VAC40-73-260-C
Description:	Based on staff interview and observation the facility failed to have a listing of all staff who have current certification in First Aid and CPR posted in the facility readily available to staff. Evidence: During the 4/27/21 inspection of the facility, there was not a posting of staff members who were certified in First Aid and/or CPR.
Plan of Correction:	Correction A copy of the listing of all staff who have current certifications in First Aid and CPR was immediately posted in the nurses? station of assisted living unit. Other Potential All residents who reside in assisted living as well as staff members have the potential to be affected. System Change The facility procedure for posting a listing of Frist Aid/CPR certified staff members was reviewed and the Unit Charge was in serviced on 7/8/22 by the facility administrator. Monitoring The facility administrator will review once weekly x4 weeks to ensure the listing of First Aid/CPR certified staff members remains updated and posted in nurses? station. Variances will be corrected as needed. Date ? July 11, 2022
Standard #:	22VAC40-73-310-B
Description:	Based on record review, the facility failed to ensure that prior to admission, an interview was documented between the administrator or a designee responsible for admission and retention decision, the individual and his legal representative to make the determination that the facility can meet the needs of the individual. Evidence: The resident records for Residents #1, #2, and #3 did not contain documentation that a determination interview had occurred between the facility and resident prior to admission.
Plan of Correction:	Correction 100% resident record audit was immediately conducted and charts missing documentation of determination interviews were noted. Other Potential All potential new assisted living residents considering residing on unit have the potential to miss their determination interview. System Change The facility administrator was in serviced by the regional director of operations on 7/6/22 regarding the expectation to conduct prior to admission and document that a determination interview was completed. Monitoring The facility administrator/designee will conduct 100% record review on all new admissions monthly x3 months to ensure determination interviews were conducted by a designee responsible for admission and retention decisions. Variances will be investigated, and corrections made as appropriate. Date ? July 11, 2022
Standard #:	22VAC40-73-550-G
Description:	Based on record review, the facility failed to ensure resident rights and responsibilities were reviewed annually with each resident or his legal representative and each staff member. Evidence: 1. Staff #1?s last documented review of Resident Rights was dated 3/16/21. 2. Staff #2, #3, and #4?s training records had a documented annual review of Resident Rights date of 1/13/21.
Plan of Correction:	Correction 100% resident record audit was immediately conducted and charts missing documentation of resident rights annual review were provided to resident/representative. 100% staff record audit was immediately conducted and those staff missing annual resident rights review were provided and signed. Other Potential All assisted living residents and staff have the potential to miss their annual resident rights review. System Change The unit charge was in serviced on 7/8/22 by the facility administrator regarding the facility policy for annual review of residents? rights and the expectation to place a signed copy in the resident medical record. Business office manager was in serviced on 7/7/22 by the facility administrator regarding policy for annual review of residents? rights and expectation to place signed copy in employee file. Monitoring The Unit Charge/designee will conduct 100% record review on the 30th of each month x3 months to ensure annual review of residents? rights is updated and signed in each chart. The facility business office manager will review staff members files on the 30th of each month x3 months to ensure annual review of residents? rights is updated and signed. Corrections made as appropriate. Date ? July 11, 2022
Standard #:	22VAC40-73-610-B
Description:	Based on observations made during the tour of the facility, the facility failed to have the menu for the current week posted. Evidence: On April 27, 2022, during the on-site inspection of the facility, the menu posted was for the week of March 20 through March 26.
Plan of Correction:	Correction An updated menu for the current week was posted immediately and copies provided to all residents at their request. Other Potential All residents who dine within the assisted living unit may have been impacted. System Change The facility procedure for posting of weekly menus was reviewed and the unit charge was in serviced on 7/8/22 by the administrator. Residents/resident representatives were educated on their rights to receive accurate weekly menus. Monitoring The administrator/designee will review, once weekly x4 weeks, to ensure weekly menus are posted and any resident requesting a copy of menu is provided one. Variances will be corrected as needed. Date ? July 11, 2022
Standard #:	22VAC40-73-720-A
Description:	Based on record review, the facility failed to ensure Do Not Resuscitate (DNR) order was included on the Individualized Service Plan (ISP). Evidence: Resident #1 and Resident #3 have DNR orders however they were not documented on the residents? ISPs.
Plan of Correction:	Correction Resident #1 and Resident #3?s ISP were reviewed and revised on 7/6/22 to reflect the resident?s code status of DNR. Other Potential Other residents who have chosen DNR may have been at risk. Care plans will be reviewed/revised as needed. System Change The interdisciplinary team will be re-educated by facility administrator on updating ISPs including the importance of including resident?s code status in the resident?s comprehensive care plan. Monitoring The facility DON/designee will review 3 resident ISP per week to ensure their current code status is captured. Variances will be investigated and corrected as appropriate. The weekly audits will be provided for trending. A summary of the weekly audits will be provided to the regional director of clinical services for additional oversight. Date ? July 11, 2022
Standard #:	22VAC40-73-860-I
Description:	Based on observation, made during the inspection of the facility, the facility failed to store hazardous material in a locked area. Evidence: On April 27, 2022, during an inspection of the facility, the laundry room was unlocked and a laundry detergent pod was observed on top of the washing machine.
Plan of Correction:	Correction Laundry room on assisted living unit was immediately locked and laundry detergent pod was removed from top of washing machine and stored securely. Other Potential All assisted living residents had the potential to be affected by unsecured laundry room, providing access to cleaning materials. System Change All assisted living team members have been re-educated by 7/8/22 regarding maintaining a locked laundry room door as well as securing laundry detergents in their designated containers. Monitoring The Unit Charge/designee will conduct random inspections of laundry room door and contents of laundry room weekly x 4 weeks to ensure door remains locked. Variances will be investigated, and corrections made as appropriate. Findings from the weekly reviews will be analyzed for trends/patterns and need for additional staff education and/or other actions. Date ? July 11, 2022
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview, the facility failed to maintain the interior and exterior of the building in good repair and keep it clean and free of rubbish. Evidence: During a tour of the facility on 4/27/22, the main women?s bathroom had floor tiles near the baseboard that were missing and loose.
Plan of Correction:	Correction Loose floor tiles in the main woman?s bathroom were immediately repaired by facility maintenance department. Tiles that were found missing from the same bathroom floor were replaced. Other Potential All persons who utilized the woman?s bathroom had the potential to be affected by a floor that was not in good repair or found to not be free of rubbish. System Change The expectation to maintain the interior and exterior of the building in good repair and kept clean and free of rubbish was re-educated to the facility maintenance director on 7/7/22. Monitoring The facility administrator will conduct random visual inspections of all flooring throughout assisted living community once weekly x 4 weeks to ensure all surfaces are in good repair. Variances will be corrected as needed. Date ? July 11, 2022
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation and interview with staff, the facility failed to ensure certain documents related to the terms of the license were posted on the premises of the licensed facility, including the most recently issued license and the findings of the most recent inspection of the facility. Evidence: During the on-site inspection on April 27, 2022, the most recent findings from the inspection dated April 22, 2021 and April 23, 2021 was not posted.
Plan of Correction:	Correction A copy of the most recent inspection dated 4/22/21 and 4/23/21 was immediately posted in the common area of assisted living unit. Other Potential All residents who reside in assisted living as well as resident representatives, visitors and staff have the potential to be affected by not reviewing annual inspection results. System Change The facility procedure for posting inspection results was reviewed and the facility administrator was in serviced on 7/6/22 by the regional director of operations. Residents/resident representatives were educated on the placement of the inspection results. Monitoring The unit charge will review once weekly x4 weeks to ensure the inspection results remain in the designated common resident living space for easy viewing. Variances will be corrected as needed. Date ? July 11, 2022