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: April 7, 2021 , April 8, 2021 and April 9, 2021

Complaint Related: Yes

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 complaint inspection was initiated on April 7, 2021 and concluded on April 9, 2021. A complaint was received by the department regarding allegations in the areas of resident care and related services, building and grounds, and staffing. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Executive Director a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law were determined; however, violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-650-B
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure prescriber orders included the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. Resident #2?s telephone orders dated 05-13-2020 and signed on 05-14-2020 documented Aspirin 81 mg, Diltiazem 120 mg, and Lidocaine 4% without diagnosis, condition, or specific indications for administering each drug. 2. Resident #2?s written orders dated 02-05-2020 documented Lorazepam 0.5 mg and Coumadin 5 mg without diagnosis, condition, or specific indications for administering each drug. 3. Staff #1 confirmed the aforementioned information was not included in the orders.
Plan of Correction:	Resident Care Director and/or designee to review all telephone medication orders weekly for missing diagnosis. Physician order sheets will be reviewed monthly for missing diagnosis. Ongoing.
Standard #:	22VAC40-73-680-E
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure medical treatments ordered by a prescriber shall be provided according to his instructions. Evidence: 1. Resident #1?s prescriber?s orders dated 03-19-2020 documented, ?THERAFIRM 15-20 KH MED SUPPORT ? APPLY IN THE MORNING AND REMOVE AT BEDTIME FOR EDEMA Indicated For Edema?. 2. Resident #1?s March 2020 Medication Administration Record documented Therafirm was not applied and/or removed 25 times. Documented reasons were ?Other: unable to find stockings, Other: unable to find, Other: will call pharmacy, and Other: not available.? 3. Staff #1 confirmed during discussion that Resident #1?s Therafirm were not applied/removed according to prescriber?s instructions.
Plan of Correction:	Resident Care Director and/or designee will review medication administration records daily for unavailable medications/treatments. All registered medication aides will be in-serviced on notifying Resident Care Director or Assistant Resident Care Director within 24 hours of not being available. Ongoing.