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: Jan. 23, 2020 and Jan. 24, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

An unannounced renewal inspection was conducted by a Licensing Representative on January 23, 2020 from 9:40 a.m. to 4:40 p.m. and January 24, 2020 from 8:44 a.m. to 4:36 p.m. There were 67 residents in care on both dates. Staff and resident records were reviewed, and interviews were conducted. Meals and activities were observed. A tour of the facility was completed. The following topics were discussed: using a current physical examination form, administrator justification for placement in the Special Care Unit, expired emergency supplies, discharge statements, hospice services and allergy reactions on Individualized Service Plans, personal data updates on residents, resident rights reviews with residents, home health physician?s orders, menu substitutions, and staff training documentation. Please submit your ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it within 10 calendar days. The plan of correction must indicate how the violation will be or has been corrected. The plan of correction must include: 1. Step(s) to correct the noncompliance with the standard(s) 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative measures.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review and interview, the facility failed to ensure the physical examinations completed by an independent physician contained known allergies and description of the person's reactions and a statement that specifies whether the individual is or is not capable of self-administering medication. Evidence: 1. Resident #2?s physical exam dated 12/05/19 identified the resident has having an allergy to Biaxin; however, the exam did not contain a description of the person?s reactions to the allergy. 2. Resident #2?s physical exam did not document whether or not the resident is capable of self-administering medication. 3. Resident #4?s physical exam dated 11/21/19 did not contain a description of the person?s reactions to known allergies, which was documented as resident having an allergy to Diazepam. 4. Additionally, resident #4?s physical exam did not document whether or not the resident is capable of self-administering medication. 5. Staff #2 and staff #3 observed and confirmed the physical examination forms for resident #2 and resident #4 did not contain known allergies and description of the person's reactions and a statement that specifies whether the individual is or is not capable of self-administering medication.
Plan of Correction:	Documentation was obtained from the physician for resident # 2 and 4 detailing whether the resident was capable of self administration of medications and reactions for noted allergies. All other admission history and physicals received after 02/01/18 were checked to ensure compliance. Resident Care Director will check all history and physical forms prior to admission to ensure required documentation is complete. Executive Director or designee will audit 5 history and physical forms per month to ensure ongoing compliance.
Standard #:	22VAC40-73-450-A
Description:	Based on record review and interview, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. The preliminary plan shall be identified as such and be signed and dated by the licensee, administrator, or his designee (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: 1. Resident #2 admitted 12/13/19. Resident #2?s preliminary Individualized Service Plan (ISP) was dated 12/16/19 and was identified as a ?72 hour ISP? on the heading. 2. Resident #5 admitted 11/01/19. Resident #?5?s preliminary ISP was dated 11/04/19 and was identified as a ?72 hour ISP? on the heading. 3. Staff #2 and staff #3 acknowledged resident #2?s and resident #5?s preliminary ISPs were not completed on or within seven days prior to the day of admission.
Plan of Correction:	Those certified to complete ISPs were re-educated and the requirements to meet DSS Standards. All other ISPs were checked to ensure compliance. Executive Director or designee will audit all new admission charts to ensure ongoing compliance.
Standard #:	22VAC40-73-660-B
Description:	Based on record review, observation, and interview, the facility failed to ensure a resident may be permitted to keep his own medication in an out-of-sight place in his room if the Uniform Assessment Instrument (UAI) has indicated that the resident is capable of self-administering medication. Evidence: 1. During facility tour with staff #1 on 01/23/20, medications were observed in resident rooms: a. Resident #1, who resides in ?Sweet Memories?, had a white pill with the number 290 on it in a cup on top of the dresser. Staff #1 identified the pill as Amlodipine Besylate 10 mg. b. Resident #3 had a Women?s Multivitamin/Multimineral bottle and Orasol Benzocaine 20% oral anesthetic gel container, on the bathroom counter. 2. Resident #1 is dependent in medication administration as documented on the UAI dated 11/29/19. 3. Resident #3 is dependent in medication administration as documented on the UAI dated 01/21/20. 4. Staff #1 observed and confirmed the medications observed in residents? rooms and that neither resident #1 nor resident #3 was capable of self-administering medications.
Plan of Correction:	The items were removed from the resident rooms that were noted. Resident rooms were checked for items in locations where resident?s dependent in medication would have access to them Training completed with all staff on observation medication administration and reporting of items with safety concern and education provided to residents and families regarding medications being secure in room for those independent in medication management only. Executive Director, Resident Care Director, or designee will completely weekly room checks and med cart checks to ensure continued compliance.
Standard #:	22VAC40-73-860-G
Description:	Based on observation and interview, the facility failed to ensure hot water at taps available to residents was maintained within a range of 105?F to 120?F. Evidence: 1. Hot water temperatures were above the required range in the following areas in ?Sweet Memories? (Safe, Secure Environment) on 01-23-20: a. Room 108 measured 129.4?F. b. Room 115 measured 123.8?F. 2. Staff #1 and staff #4 observed and acknowledged the hot water temperatures were above the required range in ?Sweet Memories?.
Plan of Correction:	Maintenance Director immediately adjusted water temperatures to be within range according to DSS Licensing Standards in the presence of the Licensing Inspector during the inspection. 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.