VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Leigh Hall
890 Poplar Hall Drive
Norfolk, VA 23502
(757) 461-5956

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: April 25, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

This was an unannounced Renewal Inspection conducted by Licensing Inspectors. This Inspection was conducted on 04/25/2019 ( 8:32 a.m. - 5:00 p.m.) During the inspection a medication observation was conducted, a tour of the facility and staff and resident records were reviewed including criminal background check for all new employees since last inspection that are currently employed by the facility. Licensing Inspector conducted residents and family interviews. The Healthcare Oversight Report, Dietician Report, Emergency Evacuation Drills, Fire Inspection, Health Inspection, and Emergency Preparedness and Response Plan were reviewed during the inspections. There were 78 residents in care during the inspection. There were violations cited on the areas of Admission, Retention and Discharge, Resident Care and Related Services and Emergency Preparedness. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain 1.) Steps to correct the noncompliance with standards (s) 2.) Measure to prevent the noncompliance from occurring again; and 3.) Person (s) responsible for implementing each step and/ or monitoring any preventive measures (s). Please send your corrective plan to me in a Word Document by 05/14/2019 or sooner. Thank you.

Violations:

Standard #:	22VAC40-73-350-B
Description:	Based on record review and interview the facility failed to complete a registered sex offender screening prior to admission. Evidence: 1. Licensing Inspector reviewed resident # 11's record which indicated the resident was admitted on 04/06/2019. Resident # 11's record indicated the sex offender screening was conducted on 04/12/2019 which was after the resident's admission date. 2. Staff # 1 told LI that a second sex offender screening was completed but did not produce a sex offender screening prior to resident # 11 being admitted into the facility during the inspection.
Plan of Correction:	Resident #11?s sex offender check dated for 4/12/2019 was placed in resident?s file. A full audit of all resident files was conducted and all sex offender?s check s are accounted for and dated correctly. ED or designee will continue to follow Commonwealth policies and procedures regarding proper completion of Sex offender checks.
Standard #:	22VAC40-73-680-G
Description:	Based on observation and interviews, the facility failed to ensure the over-the-counter medication remains in the original container, labeled with the resident?s name, or in a pharmacy-issued container, until administered. Evidence: 1. Licensing Inspector (LI) conducted a medication observation and observed in the Special Care Unit ( SCU) medication cart # 2; Resident # 1's Melatonin 5 mg was not labelled. 2. Resident # 2's in the assisted living section of the facility medication cart # 2; Resident # 2's Extra Strength Antacid (Calcium Carbonate) was not labelled. 2. Staff # 4 and # 5 acknowledged that the resident's medications were not labelled during review of the medication carts.
Plan of Correction:	The medicines for resident #1 and #2 were labeled with correct name and information. RCD, ARCD, or designee will continue with bi-weekly med-carts audits to assure continued compliance. Staff members #4 and #5 were in-serviced on correct labeling of medications. RCD or designee will conduct a monthly random review or medication labeling.
Standard #:	22VAC40-73-680-I
Description:	Based on observation, record review and interview, the facility failed to ensure that the Medication Administration Record (MAR) includes the diagnosis and specific indications for administering each drug or supplement. Evidence: 1. Resident # 3's Divalproex EC tab 125 mg was missing a diagnosis on the April 2019 Medication Administration Record ( MAR). 2. Resident # 7's Atorvastatin 20mg and Ferrous Sulf 325 mg were missing diagnosis on the April 2019 MAR. 3. Resident # 7 interview revealed the resident receives oxygen. However, the April 2019 MAR did not have resident # 7's oxygen listed or the instruction on administering the oxygen on the MAR. There is no documentation indicating resident # 7 is receiving oxygen as ordered by the physician. 3. Staff # 2 acknowledged resident # 7's oxygen order was missing from the MAR.
Plan of Correction:	Resident #7 and Resident #3?s diagnosis?s were put on the physician orders sheet. RCD, ARCD, or designee will continue to review all orders as they come in to assure the DXs are on the physician orders sheets and all in-coming orders. The Oxygen for resident #7 was put on the resident?s MAR. RCD, ARCD, or designee will continue to monitor MARs with random periodic MAR reviews for continued compliance.
Standard #:	22VAC40-73-950-C
Description:	Based on record review and interview the facility failed to implement an orientation and semi-annual review on the emergency preparedness and response plan for all residents. The review shall be documented by signing and dating. Evidence: 1. Licensing Inspector (LI) reviewed facility's emergency preparedness with staff # 1 and observed there was no documentation that was signed and dated indicating that the review of the emergency preparedness was conducted for the residents. 2. Staff # 1 confirmed there was no documentation for the residents of the facility's emergency preparedness.
Plan of Correction:	The Executive Director and Maintenance Director will hold the semi-annual emergency preparedness review with residents and have residents sign accordingly. The Executive Director in-serviced the Maintenance Director on the expectation that the semi-annual emergency preparedness review must be conducted with residents as well. Going forward the Maintenance Director will conduct the semi-annual drill with residents and the ED or designee will follow up to assure documentation of completion before filing.
Standard #:	22VAC40-73-970-E
Description:	Based on record review and interview the facility failed to ensure that the required fire and emergency evacuation drills record include the date and time of the drills. Evidence: 1. Licensing Inspectors (LIs) reviewed the fire drills with staff # 1 and observed that the fire drill documentation was missing complete dates and times that the drills were conducted. 2. The fire drill documentation had , "1/8 " for the date and "1:00 " for the time and "2/7" and "6:30" which does not indicate a complete date and time the required drills were conducted. There was no year or a.m. or pm indicated for the fire drills. 3. Staff # 1 acknowledged the missing information on the fire drill documentation during the inspection.
Plan of Correction:	The Maintenance Director scribed the correct time and year delineations on the fire drills for 1/8 and 2/7. The Executive Director in-serviced the Maintenance Director on making sure the year and time delineations are recorded on the fired drills. Maintenance Director going forward will bring fire drills to Executive Director to review before filing. Date of Compliance: 4/25/19