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: May 9, 2023

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Technical Assistance:

Ensure all staff records are retained at the facility.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced mandated renewal inspection took place on 05/09/2023 at 8:43 am to 5:02 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 20 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 staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None An exit meeting will be 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0530 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-120-A
Description:	Based on the record review the facility failed to ensure the orientation and training required in subsection B and C of this section shall occur within the first seven working days of employment. Evidence: 1. The record for staff #3, hire date 04/24/23, does not contain documentation of staff orientation.
Plan of Correction:	Correction Staff orientation was completed by staff #3 and documented on 05/21/23. Other Potential All assisted living residents as well as team members, have the potential to be affected by a facility administrator that fails to complete relevant on-boarding education. System Change The facility administrator and team members will complete the minimum of relevant education hours for newly hired employees. Monitoring The assisted living manager or designee will follow-up with the facility administrator every 14days x1 month, then monthly thereafter, to ensure that on-boarding education is completed and ensure documentation of complete hours complies and entered SNF-Clinic training platform. Variances will be corrected with notification to regional director of operations as needed.
Standard #:	22VAC40-73-150-B-1
Description:	Based on review the facility failed to notify the department?s regional licensing office in writing within 14 days of change in a facility?s administrator, including the resignation of an administrator, appointment of an acting administrator, and appointment of a new administrator. Evidence: 1. The regional licensing office received an email on 06/29/22 stating staff #7 was the administrator assigned to facility as of 06/28/22. During the onsite inspection on 05/09/23, staff #1 and staff # 3 informed the inspector of the following changes in administrator: staff #7 has not been employed with the facility since Oct. 2022; staff #8 was the next assigned administrator and has not been employed with the facility since April 2023; staff # 3 is the facility?s administrator as of 04/24/23. 3.The regional license office did not receive notification in writing of a change in the facility?s administrator to include resignation of staff #5, appointment of an acting administrator, and appointment of staff #3 as the administrator.
Plan of Correction:	A company letterhead notification letter was sent to the DSS regional licensing office on 05/12/23 to provide information on the current administrator assigned to the facility. Other Potential All residents who reside in assisted living as well as all staff have the potential to be affected by non-notification of current facility administrator. System Change The current facility administrator was in serviced on 05/24/23 by the regional director of operations regarding the expectation to notify the regional licensing office within 14 days of change in administrator, including the resignation of an administrator, appointment of an acting administrator, and appointment of a new administrator. Monitoring The business office manager will follow up with facility administrator to ensure no changes have occurred or plan to occur with acting administrator every 14days x1 month, then monthly thereafter. Variances will be corrected with notification to regional director of operations as needed.
Standard #:	22VAC40-73-210-D
Description:	Based on the staff record review the facility failed to ensure training for medication aides include continuing education required by the Virginia Board of Nursing, Evidence: 1. The Regulations Governing the Registration of Medication Aides by Virginia Board of Nursing, section 18VAC90-60-100-B, state that a medication aide shall have four hours each year of population-specific training in medication administration in the assisted living facility in which the aide is employed; or a refresher course in medication administration offered by an approved program 2. The record for staff 2, a registered medication aide, hire date 04/06/2020, did not contain documentation of the staff completing the required annual continuing education or a refresher course in medication administration for the dates of 4/06/2020 to 05/08/2023.
Plan of Correction:	Correction Areas were corrected and education provided to medication aide. Other Potential All assisted living residents receiving medication in the facility have the potential to be affected by deficient practice. System Change Medication aides completed a four (4) hour medication administrating refresher course via SNF Clinic-CEU on 05/26/23. Monitoring The assisted living manager or designee will follow up with the facility administrator to ensure 4 hours of education is completed and documented within the medications? aide?s employee file. Variances will be corrected with notification to regional director as needed.
Standard #:	22VAC40-73-310-H
Description:	Based on the record review the facility failed to ensure in accordance with 63.2-1808 of the Code of Virginia, assisted living facilities shall not admit or retain individuals with any of the following conditions or care needs: psychotropic medications without appropriate diagnosis and treatment plans. Evidence: 1. Resident #5?s medication administration record (MAR) for May 2023 documents the resident is prescribed, Paroxetine HCI for depression. The record does not contain documentation of a treatment plan for the psychotropic medication, Paroxetine HCI.
Plan of Correction:	Correction The Medical Director was notified and reviewed the resident?s chart on 5/18/23. He entered an order for a gradual dose reduction (gdr) for Paxil. Also, verified that medication was needed to treat depression. Other Potential All assisted living residents receiving medication in the facility have the potential to be affected by deficient practice. System Change The assisted living team members will be educated on how to identify proper diagnoses documentation related to a resident?s psychotropic medication and notify the Medical Director in a timely manner. Monitoring The assistant living manager or designee will conduct 100% review audit x 30days and follow up with the administrator to ensure that all psychotropic medications contain documentation of a treatment plan. Variances will be corrected as needed. Completion date of 6/25/23 and audit results will be reported in QAPI for oversight and recommended changes.
Standard #:	22VAC40-73-320-A
Description:	Based on the record review the facility failed to ensure within 30 days preceding admission a person shall have a physical examination to include the following: results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form. Evidence: 1. The record for resident #5, admission date 05/02/2023, did not include documentation of a risk assessment documenting the absence of TB.
Plan of Correction:	Correction Resident #5 TB screening was refused by resident/family and documented on 05/10/23. Other Potential All assisted living residents who live in the facility have the potential to be affected by deficient practice. System Change A 100% TB audit was conducted and completed for all assisted living residents by the SDC on 05/10/23. Monitoring The assistant living manager or designee will complete, review, and maintain a new hire checklist to ensure that the proper documentation is submitted upon admission. The facility administrator will conduct a 100% audit on all new admissions x3 months. Variances will be corrected as needed.
Standard #:	22VAC40-73-350-B
Description:	Based on the record review the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater three days or in fact stays longer than three days and shall document in the resident?s record that this was ascertained and the date the information was ascertained. Evidence: 1. The record for resident # 4, admission date 02/14/23, contains a sex offender screening dated 05/09/23 which was completed after the resident?s admission.
Plan of Correction:	Correction Occurred in the past unable to correct. Other Potential All Assisted Living residents have the potential to be affected by deficient practices. System Change All assisted living residents will have a sex offender screening completed prior to admission. Monitoring The assistant living manager or designee will complete, review, and maintain a new admission checklist to include the sex offender screening, to ensure that the proper documentation is submitted upon admission. The facility administrator will conduct a 100% audit of new admission documentation x3 months. Variances will be corrected as needed.
Standard #:	22VAC40-73-410-A
Description:	Based on the onsite record review the facility failed to ensure upon admission, the assisted living facility shall provide an orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of the call system. Acknowledgement of receiving the orientation shall be signed and dated by the resident and as appropriate his legal guardian, and such documentation shall be kept in the resident?s record. Evidence: 1. The record for resident # 4, admission date 02/14/23, did not contain documentation of completion of an orientation.
Plan of Correction:	Correction Occurred in the past unable to correct. Other Potential All Assisted Living residents have the potential to be affected by deficient practices. System Change Orientation for resident #4 and family was completed on 05/09/23. All assisted living residents will have the completion of an orientation and documentation into the facility upon admission. Monitoring The assistant living manager or designee will complete, review, and maintain a new admission checklist and documentation of orientation to ensure that the proper documentation is submitted upon admission. The facility administrator will conduct a 100% audit of new admission documentation x6 months. Variances will be corrected as needed.
Standard #:	22VAC40-73-450-E
Description:	Based on the record review the facility failed to ensure the Individualized Service Plan (ISP) shall be signed and dated by the licensee, administrator, or his designee and by the resident or his legal guardian. Evidence: 1. Resident #4?s ISP includes an identified needs date of 02/06/23. The ISP was not signed and dated by the licensee, administrator or his designee, the resident or the legal guardian.
Plan of Correction:	Correction Occurred in the past unable to correct. Other Potential All assisted living residents residing in this facility have the potential to be affected by a facility that does not effectively have the Individualized Service Plan (ISP) signed and dated or by its staff, residents or the legal guardian. System Change The assisted living manager was in-serviced by the administrator on 05/23/23 regarding the expectation to have the ISP signed by the facility administrator or designee, the resident or the legal guardian. Monitoring The assistant living manager or designee will complete, review, and maintain a new admission checklist and documentation of orientation to ensure that the proper documentation and signatures is submitted. The facility administrator will conduct a 100% audit of new admission documentation x3 months. Variances will be corrected as needed.
Standard #:	22VAC40-73-640-A
Description:	Based on observation the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated medications. Evidence: 1. During observation of the medication cart with staff #2, the following expired medications were located on the medication cart: Metformin Hydrochloride, expired 03/28/23; Loperamide Hydrochloride, expired 09/22.
Plan of Correction:	Correction Areas were corrected and education provided to staff #2. Immediate medication audit was completed on 05/09/23. All expired medications were removed and destroyed. Other Potential The assistant living resident has the potential to be affected by deficient practice. System Change Assisted living will implement a written agenda and staff will be educated about expired medications on the carts and proper discarding of those expired medications. Monitoring The assist living manager or designated will conduct 100% audit on the 30th of each month x3 months to ensure that all expired medication is removed and properly disposed. Variances will be investigated, and corrections made appropriate. Completion date of 8/25/23 and audit results will be reported in QAPI for oversight and recommended changes.
Standard #:	22VAC40-73-860-G
Description:	Based on observation the facility failed to ensure the hot water at taps available to residents shall be maintained within a range of 105?F to 120?F. Evidence: 1. During the onsite inspection, the water temperature in resident # 7?s room was measured 100.1 degrees F. The water temperature in resident # 5?s room was measured to 96.0 degrees F.
Plan of Correction:	Correction Director of Maintenance called qualified plumber contractor. Waiting for corporate to accept quote to replace the mixing value on the boiler. Other Potential All Assisted Living residents have the potential to be affected by deficient practices. System Change Maintenance staff will conduct random audits x4 weeks to check the hot water temperature in resident rooms x4 weeks after the completion of repairs to the boiler. Monitoring The maintenance director or designee will conduct a weekly audit x6 months to ensure that the mixing value is maintain the proper hot water temperature of 105 to 120 F once the boiler is repaired. Variances will be corrected as needed.
Standard #:	22VAC40-73-970-A
Description:	Based on review the facility failed to ensure fire and emergency drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills requested for each shift in a quarter shall not be conducted in the same month. Evidence: 1. The facility did not provide record of a fire drill completed for the months of Dec. 2022, Jan. 2023, and Feb. 2023.
Plan of Correction:	Correction Occurred in the past unable to correct. Other Potential All Assisted Living residents have the potential to be affected by deficient practices. System Change Maintenance Staff was in-services by the facility administrator on 05/23/23 regarding the expectation to conduct fire drills monthly and quarterly for staff and residents residing in the assisted living based on OSHA standards, and document when the drills are completed. Monitoring The facility administrator will conduct a 100% monthly and quarterly audit of all fire drills x6 months to ensure that fire drills are completed and documented in a timely manner. Findings from audits will be analyzed and addressed in a timely manner. Audit results will be reported in QAPI for oversight and recommended changes.
Standard #:	22VAC40-73-970-E
Description:	Based on review the facility failed to ensure the record of the required fire and emergency evacuation drill shall include the number of staff and residents participating in the drill. Evidence: 1. The facility?s fire and emergency evacuation drills completed on 03/31/23 and 04/03/23 did not include documentation of the number of staff and residents participating in the drill.
Plan of Correction:	Correction Occurred in the past. Unable to correct Other Potential All assisted living residents have the potential to be affected by deficient practices. System Change Maintenance staff will conduct scheduled fire and emergency evacuation drills in the assisted living to include the proper documentation of assisted living residents and staff who participated in the drill. Monitoring The facility administrator will conduct a 100% monthly audit of the documentation of all fire and emergency evacuation drills x6 months to ensure the completion of the documented. Findings from audits will be analyzed and addressed in a timely manner. Audit results will be reported in QAPI for oversight and recommended changes.
Standard #:	22VAC40-90-40-B
Description:	Based on the onsite record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each staff person. Evidence: 1. The record for staff #3, hire date 04/24/2023 does not contain documentation of a criminal history report.
Plan of Correction:	Correction Criminal background check for staff #3 was completed and documented on 05/09/23. Other Potential All assisted living residents have the potential to be affected by deficient practices. System Change All assisted living team members will have their criminal history background check completed and documented on or prior to the 30th day of employment. Monitoring The administrator or designee will complete, review, and maintain a new hire checklist to ensure that the proper documentation is submitted upon admission. The facility administrator will conduct a 100% audit of new hire documentation x3 months. Variances will be corrected as needed.