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: Sept. 19, 2023

Complaint Related: Yes

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 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 09/19/2023 from 8:48 a.m. to 2:18 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 09/06/2023 regarding allegations in the area(s) of: Admission Retention and Discharge of Residents and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 60 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 4 Observations by licensing inspector: The call bell system was monitoring and an observation of lunch was completed. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations: area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint 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 #:	22VAC40-73-440-A
Complaint related:	Yes
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 in the resident?s condition. Evidence: 1. The record for resident #1 contains the following: a progress note dated 08/30/23 that documents ?the resident will return with nephrostomy care and orders to flush twice a week, which will be completed by Home Health;? a physician referral dated 08/31/23 for the resident to receive home health care services; a home health care plan documenting a start date of 09/02/23 for the resident to receive skilled nursing services for nephrostomy tube care. The record for resident #1 contains a UAI dated 07/11/23. The resident?s record did not contain completion of a UAI when there was a significant change in the resident?s care to include Home Health Services for the need of nephrostomy tube care.
Plan of Correction:	Resident UAI has been updated to include significant change in the resident?s care to include home health services needed for the nephrostomy tube Resident Care Staff will be educated on updating UAI?s when there is a significant change in the resident?s care over the next 90 days the RCD/designee will be completing a review of current UAIs/ISPs to assure they reflect current needs of resident.
Standard #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission. Evidence: 1. The record for resident #2, admission date of 07/30/23, contains a Preliminary Plan of Care dated 07/27/23. The record did not contain an ISP completed 30 days after admission.
Plan of Correction:	Resident ISP has been completed and updated Resident Care Staff will be educated on completion of ISP within 30 days of admission over the next 90 days the RCD/designee will be completing a review of current UAIs/ISPs to assure they reflect current needs of resident.
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure the ISP shall be reviewed and updated as needed for a significant change in the resident?s condition. Evidence: 1. The record for resident #1 contains the following: a progress note dated 08/30/23 that documents ?the resident will return with nephrostomy care and orders to flush twice a week, which will be completed by Home Health;? a physician referral dated 08/31/23 for the resident to receive home health care services; a home health care plan documenting a start date of 09/02/23 for the resident to receive skilled nursing services for nephrostomy tube care. The record for resident #1 contains an ISP dated 07/11/23. The resident?s record does not contain documentation to include a review and update of the ISP to reflect the resident?s condition to include the need for home health services for nephrostomy care.
Plan of Correction:	Resident ISP has been updated to include the need for home health services for nephrostomy care Resident Care Staff will be educated on the need to review and update the ISP to reflect the resident?s condition over the next 90 days the RCD/designee will be completing a review of current UAIs/ISPs to assure they reflect current needs of resident.