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: Dec. 30, 2020 , Jan. 4, 2021 and Jan. 5, 2021

Complaint Related: No

Areas Reviewed:

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 monitoring inspection was initiated on December 28, 2020 and concluded on January 5, 2021. The Executive Director was contacted by telephone to initiate the inspection. The Executive Director reported that the current census was 55. The inspector emailed the Executive Director a list of items required to complete the inspection. The inspector reviewed 5 resident records, along with policy documents submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Consultation was provided regarding administering medications according to a physician?s order and individualized service plans being updated accordingly.

Violations:

Standard #:	22VAC40-73-550-D
Description:	Based on record review and discussion, the facility failed to establish written policies and procedures for implementing ?63.2-1808 of the Code of Virginia. Evidence: 1. A copy of the written policies and procedures for implementing ?63.2-1808 of the Code of Virginia [Rights and Responsibilities of Residents of Assisted Living Facilities] was requested. 2. Staff #1 indicated that the facility did have the requested written policies and procedures; however, Staff #1 provided via email; a document titled, ?Resident Programs- Section 14 Smile Standards? which documented, ?It is the responsibility of the Program Director to maintain and update the Residents Rights signatures every year?? Staff #1 stated, ?This is the only policy I could find in reference to resident rights.?
Plan of Correction:	Executive Director contacted Regional Vice President. Regional Vice President notified Vice President of Resident Programs. A new policy was created and put in place for resident rights on February 12,2021.
Standard #:	22VAC40-73-680-I
Description:	Based on record review and discussion, the facility failed to ensure the Medication Administration Record (MAR) included initials of direct care staff administering the medications. Evidence: 1. Residents? October, November, and December 2020 MARs did not contain the initials of direct care staff (DCS) who administered the following medications: A. Resident #1?s MARs did not have 68 sets of DCS? initials documented for Rosuvastatin Calcium, Fish Oil, Theratrum Complete, Olanzapine, Metoprolol, Aspirin, DOK Oral Capsule, Hydrochlorothiazide, Memantine and Omeprazole; B. Resident #2?s MARs did not have 28 sets of DCS? initials documented for Lorazepam, Amlodipine Besylate, Eliquis, Flecainide Acetate, Metoprolol, and Spironolactone; and C. Resident #3?s MARs did not have 3 sets of DCS? initials documented for Xiidra Ophthalmic Solution, and Simbrinza Ophthalmic Suspension. 2. Staff #1 acknowledged during discussion that the aforementioned medications were not initialed by direct care staff who administered the medications. Staff #1 did not provide any additional documentation with the DCS? initials for the aforementioned MARs.
Plan of Correction:	Resident Care Director and/or designee will review Medication Administration Record daily for omitted initials. Paper medication records will be printed monthly to ensure that medications can be documented in the event of electronics failure. All registered medication aides will be in serviced on how to document medication passes, when electronic devices are not working properly.