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: Jan. 15, 2020 and Jan. 16, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

An unannounced monitoring inspection was conducted on January 15, 2020 from 9:30 am to 4:50 pm and January 16, 2020 from 9:34 am until 3:42 pm. There were 53 residents in care. During the inspection, a tour of the building and grounds was conducted. A medication administration observation was conducted. Medication carts, resident records, and staff records were reviewed. Criminal background checks for all new staff hired since the previous inspection were reviewed. The facility's emergency supplies were reviewed. There was discussion regarding Individualized Service Plans (ISPs), physician's orders to be reviewed for completeness. Individuals qualified to complete the Health Care Oversight and requirements for menus were discussed. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice. The plan of correction must indicate how the violation will be or has been corrected. Your plan of correction should include: 1. Step(s) to correct the non-compliance with the standard(s) 2. Measures to prevent re-occurrence; and 3. Person(s) responsible for implementing each step and/or monitoring any preventive action(s). The plan of correction is due within 10 calendar days on or before 2/20/2020.

Violations:

Standard #:	22VAC40-73-290-A
Description:	Based on record review and interview, the facility failed to include the job classifications of all staff working each shift, with an indication of who was in charge on the written work schedule. Evidence: 1. Staff schedules from 11-18-19 to 01-16-2020 did not include the job classifications of all staff or an indication of who was in charge. The schedules identified the "med tech" only. 2. During interview, staff #1 acknowledged the written work schedules did not include the job classifications or an indication of the person in charge.
Plan of Correction:	Scheduler reeducated to ensure that the job classifications and person in charge are noted on the schedule with all the required elements. The Executive Director, Resident Care Director, and Assistant Resident Care Director will review printed schedules to ensure continued compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview, the facility failed to ensure the comprehensive Individualized Service Plan (ISP) included a description of the resident's identified needs. Evidence: 1. Resident #6 had a Guardian as of 8-29-18, and a physician's order dated 12-9-19 for a mechanical soft diet. 2. Resident #6's ISP dated 3-3-19 did not document the resident's need for a Guardian or a mechanical soft diet. 3. Staff #1 acknowledged resident #6's ISP did not include a description of the resident's needs.
Plan of Correction:	The Resident Care Director or designee will ensure that each ISP is reviewed and updated annually or if there is a change in the resident condition to include the assessed needs as per the UAI. Resident #6 ISP was updated to reflect assessed needs. The ISPs of other residents were reviewed to ensure compliance. Records reviewed to include identified need and what type of assistance staff are to provide to include coordinated services, basic needs identified, and signature of legal representative. Community will continue to complete Preliminary ISP and Comprehensive ISP in conjunction with resident, family, and/or caregivers while using the History and Physical, physician orders, UAI, and other support to ensure the individualized basic needs of the resident are adequately identified to include type of assistance needed to protect the resident?s health, safety, type of assistance required by coordinated services if applicable, and required signatures. Executive Director will review the Preliminary ISP on the date of admission. Executive Director, Resident Care Director, and/or designee reviewed other ISPs to ensure compliance. Executive Director will complete random monthly audit of a minimum of 5 Comprehensive ISPs to ensure ongoing compliance.
Standard #:	22VAC40-73-650-C
Description:	Based on record review and interview, the facility failed to ensure verbal orders were reviewed and signed by a physician or other prescriber within 14 days. Evidence: 1. On 1-16-2020, resident #10 had a verbal order dated 12-26-19 for Ensure dietary supplement and discontinue Sertraline, Ropinirole, Midodrine, Entacapone, and Cabidopa-Levodopa. The verbal order was not signed or dated by the prescriber. 2. Staff #1 acknowledged the verbal order was not signed. Staff #1 contacted the prescriber during the inspection and provided a signed copy of the verbal order which was not dated.
Plan of Correction:	A signed order was obtained from the prescriber. Resident Care Director reviewed all prescriber?s oral orders to ensure that they are signed by a physician or other prescriber as required by BON and Licensing Standards. Resident Care Director, Assistant Resident Care Director, or designee will review all oral orders daily to ensure continued compliance.
Standard #:	22VAC40-73-680-G
Description:	Based on observation and interview, the facility failed to ensure over-the-counter medications were labeled with the resident's name or in a pharmacy issued container. Evidence: 1. On 1-15-2020, three over-the-counter medications on the "West side" medication cart (Areds 2 Macular Shield, Glucosamine Supplement, and Aspirin 81mg) were not labeled with the resident's name or in a pharmacy issued container. 2. Staff #4 stated the medications belonged to resident #3. Staff #4 acknowledged the medications were not labeled with the resident's name or in a pharmacy issued container.
Plan of Correction:	Resident Care Director to re-educate RMAs on the 5 right of medication administration to include medication label requirements. All medications in the cart were audited to ensure that labeling was present to ensure compliance. Resident Care Director or designee will complete a random audit of Medications stored in the cart a minimum of 1 time per week to ensure continued compliance.
Standard #:	22VAC40-73-870-E
Description:	Based on observation and interview, the facility failed to ensure window coverings were kept in good repair and condition. Evidence: 1. On 1-15-2020, the window blinds in room #24 had four (4) broken slats that were partially detached and hanging from the blinds. The bottom rail (base) of the blinds was hanging by the threads and resting diagonally on the window sill. 2. Staff #4 and staff #1 acknowledged the window blind was not in good repair.
Plan of Correction:	Blinds in room # 24 were replaced. All other areas were checked to ensure compliance. 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 #:	22VAC40-73-980-H
Description:	Based on observation, the facility failed to ensure at least 48 hours of the supply of emergency drinking water was on site at any given time. Evidence: 1. On 1-16-2020, the facility had 57 gallons of drinking water on site. The total number of residents in care was 53. 2. Staff #1 and staff #7 acknowledged the facility did not have at least a 48 hour supply of emergency drinking water on site at the time of inspection.
Plan of Correction:	The additional water was ordered and delivered to the community to ensure the DSS required amounts were on hand at the community. Dining Services Director or designee will ensure that community will have required emergency food and water supply on site and will check monthly for continued compliance. Executive Director will audit by the 25th of every month to ensure continued compliance.