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: Nov. 15, 2022

Complaint Related: No

Areas Reviewed:

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 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 11/15/22 at 8:16 am to 12:30 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 11/03/2022 and 11/04/2022 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 55 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: The following were reviewed: staffing schedule, plan for resident emergencies and practice exercises, and observation of the exit doors in the memory care unit. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self- report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia. peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1150-A
Description:	Based on staff interview, the facility failed to ensure doors that lead to unprotected areas be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates for residents residing in a safe, secure environment. Evidence: 1. Staff # 1 and Staff #4 acknowledged resident #1 exited an exit door in the safe, secure unit that was unlocked and not working properly. The exit door leads to an unsecured parking lot outside of the facility. 2. An incident report referencing Resident #1 dated 11/04/22 documents the ?exit doors was not working properly and was repaired on 11/04/22.?
Plan of Correction:	West wing exit door on right side of community, was repaired on November 4, 2022. Maintenance Director to check door weekly for operation failure.
Standard #:	22VAC40-73-450-C
Description:	Based on the onsite record review the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission. Evidence. 1. Resident #1 record documents an admission date of 3/18/22. 2. Resident #1 record includes a Preliminary ISP dated 3/17/22. The Comprehensive ISP in the record is dated 09/17/22. 3. Staff # 4 acknowledged the ISP for resident #1 documents a completed date of 09/17/22. 4. Resident #2 record documents an admission date of 06/05/22. The record includes a Preliminary ISP dated 06/05/2022. 5. Resident # 2 record did not include documentation of a Comprehensive ISP. 6. Staff #4 acknowledged a Comprehensive ISP was not completed and included in the record for resident #2.
Plan of Correction:	Resident Care Director, Assistant Resident Care Director and Executive Director audit new resident charts monthly, to ensure all 30-day comprehensive ISP?s are completed in a timely manner.
Standard #:	22VAC40-73-460-D
Description:	Based on staff interview and the record review the facility failed to provide supervision of resident schedules, care, and activities including attention to specialized needs, and wandering from the premises. Evidence: 1. An incident report referencing Resident #1 dated 11/04/2022 documents ? On 11/03/22 at 4:40 pm, the resident eloped out of the community and was missing for approximately 20 minutes.? The resident was located at 5:01pm by the police outside of a daycare center. The resident was returned to the facility by the police. 2. Staff #1 and staff #4 acknowledged the staff on duty was not aware resident #1 exited the facility?s safe, secure unit until receiving a call stating the resident was returning to the facility by the police. 3. Resident #1 physical exam report dated 03/16/22 documents a diagnosis of Alzheimer?s Disease and Dementia. The physical exam reports the resident is not oriented to time or place and his judgement and insight is impaired. 4. Resident #1 record documents an approval for placement in the special care unit dated 03/17/2022.
Plan of Correction:	Resident #1 was placed on hourly rounds and staff were inserviced on missing persons, elopement protocols and the importance of knowing where the resident is located at all times.