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 22, 2023

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 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Technical Assistance:

Weekly Breakfast Menu to be kept current

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 03/22/2023 from 8:15am to 4:56pm. 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: 57 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast, Lunch and an activity were observed. A medication pass observation was completed for four 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. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None 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 #:	22VAC40-73-430-H-1
Description:	Based on the record review the facility failed to ensure at the time of discharge, the assisted living facility shall provide to the resident, and as appropriate his legal representative and designated contact person a dated statement signed by the licensee or administrator that contains the following information: the resident?s destination. Evidence: 1. The record for resident #8, contains a discharge statement dated 01/12/23 that does not include the resident?s destination.
Plan of Correction:	The Resident Care Director and/or designee will assure that discharge statements are completed, to include discharge destination, per regulatory standards. Monthly, the Executive Director/designee, will review residents discharged, during that month, to assure discharge statements are completed with appropriate information per regulatory requirements.
Standard #:	22VAC40-73-440-A
Description:	Based on the record review the facility failed to ensure the uniform assessment instrument (UAI) shall be completed whenever there is a significant change of the resident?s condition. Evidence: 1. The record for resident #7 contains a physician order dated 02/15/2023 for a hospice admission and treatment. The UAI in the record is dated 01/16/23. The record does not contain a UAI completed when there was a significant change in the resident?s condition for the hospice admission and treatment.
Plan of Correction:	Resident Care Director and Assistant Resident Care Director have reviewed what constitutes a ?significant change of condition?. At least weekly, the Resident Care Director, Assistant Resident Care Director and Executive Director and/or designees will meet to discuss any significant changes in resident status/needs that would warrant an update to the UAI. UAI will be updated when appropriate.
Standard #:	22VAC40-73-450-C
Description:	Based on the record review the facility failed to ensure the Individualized Service Plan (ISP) includes a description of identified needs based upon the UAI. Evidence: 1. Resident #2?s UAI dated 01/25/2023 documents mechanical & human help needs for dressing and mobility. The ISP dated 01/25/2023 does not include documentation of the mechanical supports needed for dressing and mobility. 2. Resident #5?s UAI dated 02/23/2023 documents mechanical help needed for dressing. The ISP dated 02/23/2023 does not include documentation of the mechanical supports needed for dressing.
Plan of Correction:	Resident Care Director and Assistant Resident Care Director to complete audit of current ISPs to assure they include description of identified needs based on UAI. Moving forward, prior to ISP being signed by Executive Director/designee the ISP will be reviewed to assure that the ISP matches needs based on UAI. Resident #8?s isp was corrected on 3/23/2023.
Standard #:	22VAC40-73-450-D
Description:	Based on the record review the facility failed to ensure when hospice care is provided to a resident the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the ISP. Evidence: 1. The record for resident #7 contains a physician order dated 02/15/2023 for a hospice admission and treatment. The record does not contain an agreed upon coordinated plan between the facility and the hospice organization. The record does not contain an ISP to include services provided by the hospice organization.
Plan of Correction:	Resident Care Director and/or Assistant Resident Care Director will meet with hospice agency, at least weekly, to discuss care coordination to assure that the ISP includes services that hospice will be providing and how often these services are provided. The Executive Director will complete regular, random audits of those residents receiving hospice services to assure ISP speaks to current hospice services being provided to resident being reviewed.
Standard #:	22VAC40-73-450-E
Description:	Based on the record review, the facility failed to ensure the ISP shall be signed and dated by the resident or the legal guardian. Evidence: 1. Resident #1?s ISP dated 01/19/2023 was not signed and dated by the resident or the legal guardian. 2. Resident #2?s ISP dated 01/25/2023 was not signed and dated by the resident or the legal guardian. 3. Resident #3?s ISP dated 01/12/2023 was not signed and dated by the resident or the legal guardian. 4. Resident #5?s ISP dated 02/23/2023 was not signed and dated by the resident or the legal guardian. 5. Resident #6?s ISP dated 02/07/2023 was not signed and dated by the resident or the legal guardian.
Plan of Correction:	Resident Care Director and Assistant Care Director will ensure all ISPs are signed prior to placement in chart. To assist in timely signature from family, the ISP will be emailed for review and signature by the POA/RP. RCD/ARCD will document attempts to obtain signature from POA/RP. The Executive Director, will complete a monthly review of ISPs completed during that month to assure appropriate signature/documentation of attempts to obtain signature.
Standard #:	22VAC40-73-640-A
Description:	Based on observation the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated medications. Evidence: 1. During observation with staff #5 the following expired medications was observed on the medication cart, and a locked refrigerator used for medication storage: Sertraline HCL tabs 25mg expired 05/27/2022; Morphine Sulfate 20mg/1ML SOLN expired 01/22/2023; Morphine Sulfate 20mg/1ML SOLN expired 12/20/2022; Morphine Sulfate 20mg/1ML SOLN expired 08/31/2022.
Plan of Correction:	Medication staff will be provided training to monitor expiration dates when meds are received and prior to administration. Resident Care Director or designee to audit medication cart weekly to assure expired medications are not available on cart. Executive Director/designee to audit medication cart monthly to review for expired medications. If expired medication will be ordered from pharmacy or D/C order will be requested if medication no longer needed.