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: Yes

Areas Reviewed:

22VAC40-73 BUILDING AND GROUNDS

Comments:

This was an unannounced Complaint Inspection conducted by Licensing Inspectors from the Eastern Regional Office located in Norfolk, Virginia. This inspection was conducted on 04/25/2019 ( 8:32 a.m.- 5:00 p.m.) There were 78 residents in care during the inspection. Licensing Inspectors investigated a complaint which alleged residents medications are not individually acknowledged as being received. The medications are received as a bundle. Medication are not reviewed and correctly documented. The facility is not secured as a safe place. Most of the time there is no one manning the entrance. Residents can easily wander out into the street. Medications are not dispersed properly. Medications have been found in residents' rooms on the floor, on furniture on the counters and in chairs. The facility is not clean. Dining and lounging chair are filthy due to urine and food from residents. Table clothes in the dining area most of the time are filthy with food and previous meals. There are shared rooms without a privacy door to the bathroom. There is concern about the respect and dignity of the residents. The facility is short staff and medication tech often are responsible for two carts. The hygiene of some of the residents is not being taken care of. The soiled linens and garments are sometime left in the resident's room which create a foul odor. The common areas are not maintained. Residents especially those that are immobile are sometime not gotten up and cleaned until 2:30 p.m. Licensing Inspectors conducted a medication observation, conducted a tour of the facility and conducted staff and resident's interviews and reviewed resident's records. Based on information gathered during the investigation the complaint is valid in regards to Building and Grounds. There were violations in the areas of Building and Grounds. Discussion During the Inspection: 1. The facility is converting all resident's medications to a new medication system. The medications are inputted by the Pharmacy and the facility is working with the Pharmacy to prevent errors. The medications come to the facility in a packet with the resident's name and medications to be administered. 2. The residents in the assisted living section of the facility are free to leave the building if they desire. However, the facility is responsible for the safety of the residents and should be aware of who is coming in and out of the building. 3. During the tour of the facility no medications were observed to be in resident's rooms, on the floor, on furniture, on the counter or in the chairs. However, the concerns have been brought to the facility's attention to monitor. 4. Staff change dining room table clothes as needed. LI advised for this task to be monitored to ensure that this task is being completed. LI observed the table clothes being changed the day of the inspection. 5. Licensing Inspectors reviewed with staff that soiled linens should be put in a plastic bag when transporting laundry to prevent odor and infection issues. 6. LI observed residents to be up and cleaned on the day of the inspection. All concerns reported were reviewed with the Administrator. 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 responses to me in a Word Document by 05/14/2019 or sooner. Thank you.

Violations:

Standard #:	22VAC40-73-870-A
Complaint related:	Yes
Description:	Based on observation and interviews the facility failed to ensure that the interior of the building is maintained and kept clean. Evidence: 1. During the tour of the facility with staff # 1, # 2 and # 3 the following was observed: a. In room # 208 the carpet was coming up at the entrance of the door. b. In room # 212 there were dark stains on the carpet and on the wall next to the bed. c. In room # 219 there was a rip in the carpet at the entrance of the bathroom. There were also stains on the carpet in front of the entrance of the bathroom. d. In room # 215 there were stains on the floor in the bathroom and in front of the bed on the left of side of the room. The carpet was rip in front of the bathroom. There are stains on the wall in the room. The door strip was missing at the bottom of the door between the bathroom and the bedroom. e. Room # 314 had a large dark stain to the left side of the bed and there were rips in the carpet. f. Room # 320 had a hole in the wall in front of the bathroom. There was damage to the door molding on both sides of the door leading to the bathroom. g. The first floor common area had wax on the floor in front of the couch on the right side of the entrance of the facility. h. There was a large carpet stain in the middle of the floor in the dining room. i. The was a small hole on the ceiling when entering the dining room in the back area. j. In the men's bathroom near the dining room there were stains on the wall behind the toilet. 2. Staff # 1, # 2 and # 3 acknowledge the areas during the tour of the facility.
Plan of Correction:	The small hole in the ceiling in the dining room was patched on 4/26/2019. All carpets including common areas and resident apartments will be cleaned and checked for rips/snags/tears, missing door strip will be re-applied to room 215, the men?s bathroom wall will be re-painted, and the hole in room 320 will be patched and the molding fixed. All housekeeping staff will begin signing and initialing their daily, weekly, and monthly tasks lists and turning them into the maintenance director. The ED or designee will review weekly with maintenance director that tasks are being completed and signed off on.
Standard #:	22VAC40-73-870-E
Complaint related:	Yes
Description:	Based on observation and interviews the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair. Evidence: 1. During the tour with staff # 1 and # 2 the following was observed: a. In room # 320 the top drawer to the sink vanity was missing. In the same room the shower strip was loose. b. There were stains on the individual chairs in the common area of the assisted living section of the facility. There were also stains and spots on the couch in the common area. c. Staff # 1 and # 2 acknowledged the areas during the tour of the facility.
Plan of Correction:	In January ED and MD compiled a list of furniture possibly needing replaced and a plan to replace furniture was put into place on Jan 1st 2019. A replacement for the top drawer in room 320 has been ordered and will be installed, shower strip was fixed on 4/26. MD will continue to use work order system to monitor repairs for community and residents and monitor during his weekly duties. ED will finalize plan for new furniture and order as applicable. ED, MD, or designee will continue to monitor status of furniture and community during weekly rounds.
Standard #:	22VAC40-73-890-B
Complaint related:	No
Description:	Based on observation and interview the facility failed to ensure that all interior areas shall be adequately lighted for the safety and comfort of residents . Evidence: 1. During the tour of the facility with staff # 1 iin room # 314 the light fixture was missing a bulb and another light bulb was blown. 2. Staff # 1 acknowledge the above during the tour.
Plan of Correction:	Light bulbs in room #314 were replaced on 4/26/2019. MD will continue to use work order system to monitor repairs for community and residents and monitor during his weekly duties.
Standard #:	22VAC40-73-920-B
Complaint related:	Yes
Description:	Based on observation and interviews the facility failed to ensure that the bathrooms provide for privacy for such activities as toileting. Evidence: 1. Licensing Inspector (LI) conducted a tour of the facility with staff # 1 and observed in shared rooms # 210, # 303 and # 320 that the area where the toilets are located the doors were removed. 2. There are french style doors that can not be locked which open into the vanity/sink area of the bathroom. 3. The bathroom allows for no privacy. The french style doors can not be locked and the doors where the toilets are located have been removed. 4. Staff # 1 acknowledged that the privacy door for the toilet area had been removed.
Plan of Correction:	ED and MD will walk community and take inventory of each room needing a bathroom door and assure doors are added to rooms. ED, MD or designee will monitor during weekly walkthroughs to assure rooms stay with in privacy compliance.