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: Dec. 12, 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 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: 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 12/12/23 from 8:35 a.m. to 5:45 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: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for two 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. 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 #:	22VAC40-73-290-B
Description:	Based on observation and staff interview the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. Upon arrival at the facility on 12/12/23 at 8:35 am the Licensing Inspector (LI) observed a posting of the Manager on Duty listed as staff #5. Staff #5 was not on site at the facility upon the LI arrival. Staff #4 acknowledged being the onsite person in charge.
Plan of Correction:	Additional Manager on Duty inserts have been ordered and will be updated in real time for onsite presence. Associates will be educated on updating signage when appropriate. Over the next 30 days the Executive Director will complete a review of signage to ensure it reflects the current on-site manager on duty.
Standard #:	22VAC40-73-440-A
Description:	Based on the record review the facility failed to ensure the uniform assessment instrument (UAI) shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident?s condition. Evidence: 1. The record for resident #1, admission date 11/16/22, does not contain an UAI completed prior to the resident?s admission date. The record for resident #1 contains an UAI that documents an assessment date of 02/20/23. 2. The record for resident #3 contains a UAI dated 02/20/23 and a hospice plan of care that includes an effective date of 06/19/23. The resident?s record does not contain an UAI completed when the resident had a significant change in condition to include the need for hospice care services.
Plan of Correction:	Resident UAI has been completed and updated Resident Care Staff will be educated on completion of UAI prior to admission, at least annually and whenever there is a significant change in the resident?s condition over the next 90 days the RCD/designee will be completing a review of current UAIs to ensure they reflect current needs of residents.
Standard #:	22VAC40-73-450-A
Description:	Based on the record review the facility failed to ensure on or within seven days prior to the day of admission a preliminary plan of shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: 1. The record for resident #1, admission date 11/16/22, does not contain a preliminary plan of care completed on or prior to admission or an individualized service plan (ISP) completed on the day of the resident?s admission. The ISP in the resident?s record is dated 10/11/23.
Plan of Correction:	Resident ISP been updated to include the basic needs of the resident that adequately protects the health, safety, and welfare. Resident Care Staff will be educated on the need to develop a preliminary plan on or within seven days prior to the day of admission over the next 90 days the RCD/designee will be completing a review of the current preliminary plan to ensure they reflect the current needs of residents.
Standard #:	22VAC40-73-450-C
Description:	Based on the record review the facility failed to ensure the ISP shall be completed within 30 days after admission and shall include a description of identified needs based upon other sources. Evidence: 1. The record for resident #3, admission date 02/14/23, contains a preliminary plan of care dated 02/14/23. The record does not contain an ISP completed 30 days after the resident?s admission date. The ISP in resident?s #3 record is dated 10/12/23. 2. The record for resident #1 contains a physician order dated 07/20/23 for a hoyer lift to aid in transfers. The facility?s health care oversight dated 07/25/23 and 07/26/23 documents the need for a ?full reassessment/ISP? for resident #1 due to the resident?s physician order for a hoyer lift. The resident?s ISP dated 10/12/23 does not include the resident?s need for a hoyer lift. The LI observed a hoyer list in resident?s #1 room on 12/08/23.
Plan of Correction:	Resident ISP has been updated to include a description of identified needs based upon other sources Resident Care Staff will be educated on the need of ISP completion within 30 days after admission over the next 90 days the RCD/designee will be completing a review of current ISP to ensure they reflect current needs of resident.
Standard #:	22VAC40-73-940-A
Description:	Based on the record review the facility failed to ensure an assisted living facility shall comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determine by at least an annual inspection by the appropriate fire official. Evidence: 1. The facility?s record contains an annual fire inspection completed on 02/21/22. Staff # 5 acknowledged the facility?s record of the last fire inspection completed is dated 02/21/22.
Plan of Correction:	Facility Annual Fire Inspection was completed on 12/14/23 Maintenance Director has been educated on the need to call and schedule the City of Norfolk Annual Fire Inspection Reminder has been added to electronic outlook calendar for Maintenance Director and Executive Director