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: Dec. 4, 2020 , Dec. 8, 2020 , Dec. 9, 2020 and Dec. 11, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

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 renewal inspection was initiated on December 4, 2020 and concluded on December 11, 2020. The Executive Director was contacted by telephone to initiate the inspection. The Executive Director reported that the current census was 53. The inspector emailed the Executive Director a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, healthcare and dietary oversights, health and fire inspections, end of shift reports, and staff schedules submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility. Consultation was provided during the inspection regarding health care oversight requirements, documentation of fire drill requirements, admission physical with ambulatory/nonambulatory status, Uniform Assessment Instruments (UAIs) , Individualized Service Plans (ISPs) being dated by resident/responsible party, and Medication Administration Record documentation requirements.

Violations:

Standard #:	22VAC40-73-1070-B
Description:	Based on record review and discussion, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident with a serious cognitive impairment, these materials or objects shall be inaccessible to the resident except under staff supervision. Evidence: 1. Resident #4?s Approval for Special Care Unit (SCU) placement was dated 03/26/2019. 2. ?End of Shift Report? notes dated 11/08/2020 documented, ?Resident [Resident #4] refused to let RMA[Registered Medication Aide] & RCA [Resident Care Aide] put [Resident #4] belt on after giving care; resident [Resident #4] placed the belt around [Resident #4?s] neck and began to tighten it, RCA removed it and placed it in the drawer under stripped towel?? 3. Staff #1 confirmed during discussion that the belt is an ordinary object that could be harmful to a resident, and Resident #4?s belt was not removed from the resident?s access.
Plan of Correction:	What Has Been Done to Correct? No resident has been adversely affected as a result of the event. How Will Recurrence Be Prevented? All of the direct care employees working in the secure unit have been educated on safe environment on the secure unit and removing any materials or objects that may be harmful to residents. Environmental rounds will be performed routinely in order to identify any potentially harmful objects in the secure unit. Person Responsible: Assistant Resident Care Director or Designee