VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Memory Care at Chesapeake
130 Great Bridge Boulevard
Chesapeake, VA 23320
(757) 436-2109

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Sept. 27, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

An announced initial inspection was conducted for Commonwealth Memory Care at Chesapeake by two Licensing Inspectors from the Eastern Regional office in the presence of the facility?s Executive Director. The inspection was conducted on September 27, 2019 from 9:05 am until 12:10 pm. There were 61 residents in care. A review was conducted with a primary focus on buildings and grounds and emergency preparedness. During the inspection, a tour of the facility was conducted as well as measurement of resident rooms. A review of the facility?s emergency supplies was conducted. A discussion was held regarding furniture in vacant resident rooms. The facility will provide the option for residents to supply their own or the facility will provide furniture for a fee. Commonwealth Memory Care at Chesapeake plans to operate as a secured memory care facility. Also discussed requirements for posting of emergency numbers by each nurses' station. An inspection will be conducted within 60 days to determine compliance with additional standards. The facility received violations in the area of Buildings and Grounds. The violations were reviewed with the Executive Director throughout the inspection and during the exit interview. Please complete your ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice. Your plan of correction should indicate how the violation will be or has been corrected. It should include: 1. Step(s) to correct the non-compliance with the Standards, 2. Measures to prevent re-occurrence, and 3. Person(s) responsible for implementing each step and/or monitoring any preventive action.

Violations:

Standard #:	22VAC40-73-860-G
Description:	Based on observation and interview, the facility failed to ensure the hot water taps were maintained within a range of 105?F to 120?F. Evidence: 1. During the tour of the facility with staff #1, 3 out of 5 bathroom water temperatures sampled did not contain hot water temperatures within the required range of 105?F to 120?F: a. On the ?East Wing? of the facility, the hot water temperature in bathroom #10 and #12 read 101.7?F. b. On the ?West Wing? of the facility, the hot water temperatures in room #7 and #9 read 100.6?F, and room #1 & #2 read 98.2?F. 2. During interview, staff #1 acknowledged the hot water temperatures in the aforementioned rooms on the ?East Wing? and the ?West Wing? were not maintained within a range of 105?F to 120?F.
Plan of Correction:	Maintenance Director immediately adjusted water temperatures to be within range. Maintenance Director will continue to round in the community daily and check water temperatures to ensure that they are between 105 degrees and 120 degrees. Executive Director will perform water temperature checks a minimum of once per week to ensure ongoing compliance.
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview, the facility failed to ensure the interior of the building was maintained in good repair and kept clean. Evidence: 1. During a tour of the building with staff #1, in the East wing, the wall in the resident shower to the right of the exit door had two nickel-sized holes under the paper towel dispenser. In addition, the ceiling vent in the bathroom was detached from the ceiling tile. 2. The wall in the resident shower to the left of the nurses? station in the west wing also had two nickle-sized holes in the wall under the paper towel dispenser. 3. The baseboards throughout the facility had a layer of dust and the white door frames throughout the facility had black marks and missing paint. 4. Staff #1 acknowledged the holes in the walls of the east and west showers. Staff #1 acknowledged the black marks and missing paint on the door frames and stated that updates to the physical plant are pending.
Plan of Correction:	Areas of concern were cleaned and repaired. Remaining areas were inspected to ensure that there were no additional cleaning or repair needs. Housekeeping cleaning schedule implemented and Maintenance and Housekeeping associates in-serviced on cleaning needs and repair. Direct care associates and housekeeping associates re-inserviced on completing maintenance repair requests when items are in need of repair. Executive Director, Maintenance Director, Resident Care Director, or designee will round a minimum of 2 times per day to ensure continued compliance.
Standard #:	22VAC40-73-870-E
Description:	Based on observation and interview, the facility failed to ensure all furnishings and fixtures, including sinks and toilets, were kept clean and in good repair and condition. Evidence: 1. During a tour of the building with staff #1, in the resident shower next to the west wing nurses? station, the cut off valve and three valve covers attached to the wall and under the sink were discolored and corroded, the white wire wall shelf was corroded, and the toilet was missing the safety cap on the large screw protruding from the base of the toilet. 2. In the west wing, the upholstered chair across from the nurses? station was missing the seat cushion and was discolored and stained with brown spots throughout the arms and back cushion of the chair. 3. In the east wing, the toilet in the resident shower located in the hall way to the right of the exit doors, was missing a safety cap on the screw protruding from the base of the toilet. 4. During interview, staff #1 acknowledged the areas mentioned were not kept clean and in good repair and condition.
Plan of Correction:	Areas of concern were cleaned and areas requiring maintenance have been repaired or replaced. Remaining areas were inspected to ensure that there were no additional cleaning, repair, or replacement needs. Housekeeping cleaning schedule implemented and Maintenance and Housekeeping associates in-serviced on cleaning needs and repair. Direct care associates and housekeeping associates re-inserviced on completing maintenance repair requests when items are in need of repair. Executive Director, Maintenance Director, Resident Care Director, or designee will round a minimum of 2 times per day to ensure continued compliance.