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: March 10, 2022 , March 11, 2022 and March 25, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 63.2 Protection of adults and reporting. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced renewal inspection was conducted by two inspector (PLO and ERO) on 3-10-22. the census was 50. A medication pass observation, breakfast meal, staff and resident records, emergency preparedness documents, interviews, water temperature, signaling observation and activities were observed. Violations were reviewed with the administrator throughout the inspection. A final exit interview was conducted with the administrator and staff on-site on 3-25-22. The acknowledgement forms were sent to the administrator via email. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. POC due within 10 days: 4-11-22

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the physical examination included all required information for two of six residents? record. Evidence: 1. Resident #3?s physical examination document dated 8-19-21 did not include the height information. 2. Resident #4?s physical examination document dated 8-19-21 did not include the height information. 3. On 3-25-22 staff #1 acknowledged the aforementioned resident?s physical did not include all required information.
Plan of Correction:	Executive Director and Assistant Resident Care Director to update resident 3 and 4 history and physical to reflect height. all history and physicals will be reviewed, to ensure that heights are included for regulatory compliance. April 15, 2022, Ongoing
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for four of six residents? record. Evidence: 1. Resident #1?s uniformed assessment instrument (UAI) dated 10-18-21 documented wheeling need as not performed, the individualized service plan (ISP) did not document what and how services would be provided. Psychosocial need documented on the ISP. The ISP did not document what and how services would be provided- resident need documented as disruptive, aggressive- and service documented- may receive special tolerance or staff training. 2. Resident #3?s UAI dated 1-13-22 documented wheeling need as not performed. The ISP dated 1-18-22 did not document what services and how it would be performed. The UAI documented behavior as appropriate. The ISP documented resident?s behavior as resistive to care. 3. Resident #5?s UAI dated 2-18-22 documented toileting need as mechanical help. The ISP dated 2-18-22 documented use of grab bars and supervision. Behavior need documented abusive, agitation greater than weekly. The ISP did not document what staff should do/what services should be provided. 4. Resident #6?s UAI dated 2-28-22 documented dressing need as mechanical help/supervision. The ISP dated 2-28-22 did not document what mechanical help was needed. Wheeling and stairclimbing need documented as not performed. The ISP did not document what/how services should be provided. Resident?s UAI documented disoriented in all spheres (time, place, and situation). The ISP did not document what services to be provided. 5. On 3-25-22 staff #1 acknowledged the aforementioned residents? record did not include all assessed information.
Plan of Correction:	Executive Director and Assistant Resident Care Director to update resident's 1,3,5 and 6 UAI's to reflect all assessed needs of residents. Assistant Resident Care Director and Executive Director to audit uai's and isp's randomly monthly, to ensure regulatory compliance. Apr 15, 2022, ongoing
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition for two of six residents? record. Evidence: 1. Resident #3?s record documented skilled nursing services with a start of service (SOC) date of 1-18-22 and another visit on 2-18-22. The record also documented physical therapy services on 1-20-22 (evaluation), 1-24-22 and 3-9-22. Resident?s record also documented mental health services from a provider, initial assessment dated 11-10-21. Another provider?s document was dated 2-9-22 with a follow-up in 3 months. 2. Resident #4?s record documented physical therapy services discontinued on 10-14-21. 3. On 3-25-22 staff #1 acknowledged the aforementioned residents? ISP did not document the therapy services and/or mental health services.
Plan of Correction:	Executive Director and Assistant Resident Care Director updated resident #3 ISP to reflect all documented services. Assistant Resident Care Director and Executive Director to audit uai's and isp's randomly monthly, to ensure regulatory compliance. April 15, 2022, Ongoing
Standard #:	22VAC40-73-680-I
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the facility medication administration record (MAR) included all required information for one of six residents? record. Evidence: 1. Resident #1?s February 2022 medication administration record (MAR) did not include the initials of the direct care staff administering the following medications on 2-27-22 at 06:00: (a) Tylenol and (b) Depakote. Ativan not initials on the following dates and time: (a) 3-1-22 at 05:00, 11:00, 17:00 and 23:00; on 3-2-22 at 05:00 and 11:00; and 3-3-22 at 23:00, 3-8-22 and 3-29-22 at 23:00. 2. On 3-25-22, staff #1 acknowledged the aforementioned resident?s medication administration was blank, did not include the initials of the direct care staff who administered the medications.
Plan of Correction:	Assistant Resident Care Director and Executive Director reviewed controlled substance book, which reflected that Ativan medication was administered. After careful review of medication card, it was noted that Depakote and Tylenol were both administered. All Registered Medication Aides were in-serviced, on the impo1iance of signing off for all medication administrations. Assistant Resident Care Director to review Medication Administration Records for omissions randomly. Executive Director to review Medication Administration Records weekly for omissions. April 15, 2022, Ongoing