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: Sept. 18, 2020 and Sept. 21, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint was received by the department on 9/14/2020 with allegations of verbal and physical abuse. A complaint inspection was initiated on 9/16/2020 and concluded on 9/22/2020. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The licensing inspector reviewed records and conducted interviews. The evidence gathered during the investigation did not support the allegations. Any violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure the Individualized Service Plan (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. The following ISP?s were not reviewed and not updated at least once every 12 months: a. Resident #2?s current ISP was dated 1/29/19. b. Resident #4?s current ISP was dated 8/6/19. 2. Staff #3 acknowledged that the ISP?s for Resident #2 and Resident #4 were not reviewed and updated as required.
Plan of Correction:	No residents were adversely affected. ISP for resident #2 dated 1/29/19 was updated on 9/22/2020. ISP for resident #4 dated 8/6/19 was updated on 9/18/2020. Individualized service plans for all existing residents were reviewed to ensure regulatory compliance by the Resident Care Director. ISP's for Residents assessed with a Change in Condition will be updated as identified for regulatory compliance. Resident Care Director or Designee will review all ISP's due for review on a monthly basis and updated at least once every 12 months and as needed.