VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Leigh Hall
890 Poplar Hall Drive
Norfolk, VA 23502
(757) 461-5956

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Nov. 14, 2022 and Nov. 17, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 11/14/22 from 8:42 a.m. to 12:30 p.m. and 11/17/22 from 8:45 a.m. to 2:38 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Breakfast, Lunch and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and call bell system was monitored. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-1090-A
Description:	Based on the record review the facility failed to ensure prior to admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia. Evidence: 1. The record of Resident #2 contains an assessment of serious cognitive impairment dated 05/28/19 which includes a response of ?No? for the question ?does this individual named above have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia.? 2. Resident # 2?s record does not include an updated assessment of serious cognitive impairment that documents a primary psychiatric diagnosis of dementia prior to the resident?s placement in the safe, secure unit on 11/23/21. 3. Staff #6 acknowledged the assessment of serious cognitive impairment in the record for resident #2 did not include documentation of a primary psychiatric diagnosis of dementia.
Plan of Correction:	The facility Nurse Practitioner shall repeat a cognitive impairment evaluation on the resident and complete a new form. This form will immediately be placed in the resident's record. Effective 12/1/2022, prior to an admission in a secured environment, all required assessments shall be conducted by a licensed professional per state regulations, to determine serious cognitive impairment due to a primary psychiatric diagnosis of dementia. All documentation shall be maintained in the resident file. The Wellness Director or Resident Care Coordinator will audit the charts to ensure all required forms and information is readily available for state inspector review.
Standard #:	22VAC40-73-1100-A
Description:	The facility failed to obtain written approval prior to placing a resident with a serious cognitive impairment in a safe, secure environment. Evidence: 1. Resident # 2?s record includes an admission date of 11/23/21 into the safe, secure unit. The record did not include documentation of an approval for placement in the safe, secure unit. 2. Staff #6 acknowledged the record for resident #2 did not include the approval for placement in the safe, secure unit. 3. Resident # 2?s record includes a medical progress note dated 8/25/22 which documents a diagnosis of dementia.
Plan of Correction:	A duplicate/replacement written approval was received from the resident POA or other authorized person(s), per state regulations and placed in the resident's medical chart for immediate review of any/all authorized people. Effective 12/1/2022, upon receiving the required medical documentation, the facility shall ensure that if memory care services are required, the Wellness Director and/or Executive Director will ensure that a written approval for . placement is obtained prior to the placement of a resident in a secured environment such a memory care unit. Immediately when requested, the suggested or otherwise required for memory . care placement, the Wellness Director or person designated by. the Executive Director shall obtain written approval from the necessary persons. Resident records will be reviewed (at least 3 per week) by the Resident Care Coordinator and Wellness Director or any other associated designated by the Executive Director. The appropriate form: Review of appropriateness of Continued Residence in Special Care Unit will be completed 6 months following the initial SCU placement and annually thereafter, per state regulations.
Standard #:	22VAC40-73-450-C
Description:	Based on record review the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs based upon the uniform assessment instrument (UAI). Evidence: 1. Resident #3?s UAI dated 05/13/22 documented a mechanical and human help need for dressing. The need for mechanical help for dressing was not included on the ISP dated 05/13/22. 2. Resident #4?s UAI dated 09/12/22 documented a mechanical help only need for transferring. The mechanical help only need for transferring was not included on the ISP dated 09/12/22.
Plan of Correction:	The ISP/UAI for the particular resident has been updated to match. Effective 12/1/2022, the Wellness Director and Resident Care Coordinator will work closely together the ensure they are conducting full resident chart audits to include and focus on ensuring all ISP's and UAl's are mirrored. Each resident ISP and UAI will be audited by the Executive Director or designee at least monthly (2 charts per month), to ensure accuracy. An ISP tickler will be utilized for easier. and more accurate tracking and reporting. The tickler shall be updated monthly and/or upon a resident's change in condition or if a family member requests additional care that we can and will provide. The ISP and UAI will remain in the resident chart for easy access for review and auditing purposes.
Standard #:	22VAC40-73-980-H
Description:	Based on the onsite observation the facility failed to ensure availability of a 96-hour supply of emergency food and drinking water. Evidence: 1. The emergency drinking water reviewed onsite with staff #2 and staff #6 included four, 1 Gallon jugs of water. There was not enough emergency drinking water for the facility current census of 56 residents.
Plan of Correction:	On 11/14/2022, 30 cases of water was purchased, and will continuously remain on site, in the designated location for emergency use. Effective 1/1/2023, a quarterly inventory review will be conducted by the dining services staff to include emergency food and water supplies are adequately? stocked (per state regulations), to include checking the expiration dates. A record will be maintained in the office of the Dining Services Director. The Executive Director may randomly audit the records to ensure compliance.
Standard #:	22VAC40-90-40-C
Description:	Based on the onsite record review the facility failed to ensure any person required to obtain a criminal history report shall be ineligible for employment if the report contacts convictions of barrier crimes. Evidence: 1. Staff #5, hired 03/21/22, criminal record report contains convictions for two barrier crimes (18.2-57.2 and 18.2-57).
Plan of Correction:	Clarification of the regulation, to include DSS interpretation of the regulation and a review of the most updated Barrier Crime List has been reviewed/discussed. The aforementioned staff member was terminated on 12/2/2022. A complete staff records background check was conducted {12/5/2022 -12/8/2022) to ensure all records were reviewed and ensure that all current employee are able to work in an Assistant Living facility and are not in violation with an unapproved barrier crime. 12/01/2022 all background check results shall be reviewed by the Business Office Manager against the most current Barrier Crimes list. The Business Office Manager will present to the Executive Director for final review and approval if qualified for.employment. The Executive Director will sign off and date each background report which has been returned to the facility by the Commonwealth of Virginia, If any person who is ineligible to work in an Assistant Living Facility, he/she will be terminated effective immediately {following notification of violation)