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: June 17, 2021

Complaint Related: Yes

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 May 5, 2021 and concluded on June 17, 2021. A complaint was received by the department regarding allegations in the areas of resident care and related services. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the (person in charge) a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and 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 #:	22VAC40-73-460-D
Complaint related:	Yes
Description:	Based on record review and discussion, the facility failed to ensure attention to specialized needs for prevention of falls. Evidence: 1. Resident #1 admitted on 04-19-2021. Resident experienced falls with hospitalizations on 04-26-2021 and 05-03-2021. The hospitalization on 05-03-2021 documented ?Closed head injury, initial encounter; traumatic hematoma of forehead, initial encounter; and fall, initial encounter?. Resident?s Progress Note dated 05-04-2021 documented, ?Resident continues to have falls?? 2. Resident #1?s Individualized Service Plan Addendum dated 04-26-2021 documented a soft helmet would be ordered for the resident as a fall risk intervention, but as of 05-04-2021 the helmet had not been ordered. 3. Resident #1?s death certificate dated 05-08- 2021 documented the cause of death as ?advanced dementia? and other significant conditions contributing to death as ?acute head injury of uncertain significance?. 4. Staff #1 confirmed the aforementioned falls occurred and the soft helmet had not been obtained prior to Resident #1?s death.
Plan of Correction:	Resident #1 helmet was supposed to be ordered by hospice company. Hospice company failed to notify community they were unable to order soft helmet. Resident Care Director and/or designee will ensure all interventions are put into place as falls occur and follow up accordingly with any outside agency for intervention. Resident Care Director and/or designee will ensure all intervention items are available prior to adding to individualized service plan. Executive Director, Resident Care Director and/or designee to meet monthly to discuss and review all high risk for falls residents monthly.