VIRGINIA DEPARTMENT OF SOCIAL SERVICES

COMMONWEALTH SENIOR LlVING AT CHURCHLAND HOUSE
4916 West Norfolk Road
Portsmouth, VA 23703
(757) 483-1780

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Feb. 8, 2024

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 02/08/24 from 8:05 a.m. to 6:21 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: 69 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: 6 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Breakfast, lunch, and activities 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, and a staffing schedule. 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 guardian and designated contact person a dated statement signed by the licensee or administrator that contains the following statement: the actions taken by the facility to assist the resident in discharge and relocation process; the date of the actual discharge from the facility and the resident?s destination. Evidence: 1.Resident?s #7, discharge statement dated 09/20/23 did not include the following documentation: actions taken by the facility to assist the resident in discharge and relocation process and the resident?s destination.
Plan of Correction:	What Has Been Done to Correct? Dated statement for resident #7 has been updated. How Will Recurrence Be Prevented? With all future discharges the facility will ensure that the resident or legal guardian and designated contact person are provided a dated statement signed by the licensee or administrator that contains the following statement: the actions taken by the facility to assist the resident in discharge and relocation process the date of the actual discharge from the facility and the residents destination. Person Responsible: Administrator or designee
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 #2 contains a hospice care evaluation and a hospice care plan with an effective date of 11/29/23. Resident?s #2 progress notes documents resident is currently receiving hospice care services. Resident?s #2 most recent UAI in the record is dated 08/23/23. The record for resident #2 does not contain a UAI completed when the resident began receiving hospice care services effective 11/29/23.
Plan of Correction:	What Has Been Done to Correct? UAI record for resident #2 was reviewed and updated accordingly How Will Recurrence Be Prevented? The community will address needs of residents during the weekly meeting and update the UAI to reflect those needs and or changes. Person Responsible: Resident Care Director or Designee
Standard #:	22VAC40-73-450-C
Description:	Based on the record review the facility failed to ensure the comprehensive individualized care plan (ISP) shall be completed within 30 days after admission. Evidence: 1. The record for resident #2, admission date 12/31/22, contains a preliminary plan of care dated 12/31/22, and an ISP completed 03/14/23 and 08/23/23. Resident?s #2 record does not contain an ISP completed within 30 days after the resident?s admission date. 2. The record for resident #3, admission date 12/15/23, contains a preliminary plan of care dated 12/14/23. The record for resident #3 does not contain an ISP completed within 30 days after the resident?s admission date. 3. Staff #6 confirmed the records for residents #2 and #3 does not contain an ISP completed within 30 days after the resident?s admission.
Plan of Correction:	What Has Been Done to Correct? The ISP record for resident #2 and resident #3 has been updated accordingly to reflect all services being rendered How Will Recurrence Be Prevented? The community will ensure that all ISP?s are completed upon admission and annually as well as when changes occur to reflect the residents needs. Person Responsible: Resident Care Director or designee
Standard #:	22VAC40-73-450-F
Description:	Based on the record review the facility failed to ensure ISPs shall be reviewed and updated at least once every 12 months and as needed for a significant change in the resident?s condition. Evidence: 1.The record for resident #2 contains a hospice care evaluation and a hospice care plan with an effective date of 11/29/23. Resident?s #2 progress notes documents resident is currently receiving hospice care services. Resident?s #2 most recent ISP in the record is dated 08/23/23. The record for resident #2 does not contain an ISP completed when the resident began receiving hospice care services effective 11/29/23.
Plan of Correction:	What Has Been Done to Correct? ISP record for resident #2 was reviewed and updated accordingly How Will Recurrence Be Prevented? The community will address needs of residents during the weekly meeting and update the ISP to reflect those needs and or changes. Person Responsible: Resident Care Director or designee
Standard #:	22VAC40-73-680-D
Description:	Based on the record review the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. The record for resident #1 contains a physician order dated 10/11/23 documenting the following instructions: ?Take blood pressure Q AM if systolic is less than 110 administer Midodrine 2.5mg.? Resident?s #1 record and the Jan. 2024 Medication administration record (MAR) does not include documentation the resident was administered Midodrine when the resident?s systolic was documented on the MAR as being less than 110 on the following dates: 01/02/24 through 01/10/24, and 01/15/24 through 01/25/24.
Plan of Correction:	What Has Been Done to Correct? The record for resident #1 was reviewed facility ensured that medication is administered in accordance with physicians orders. How Will Recurrence Be Prevented? RMAs will be receive a training on following MD orders. RMAs will receive a training on proper data input of blood pressure readings on MAR. Person Responsible: Resident Care Director or Designee
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 determined by at least an annual inspection by the appropriate fire official. Evidence: 1. The facility?s record contains an annual fire inspection completed on 02/14/22. Staff # 6 acknowledged the facility?s record of the last fire inspection completed is dated 02/14/22 and the facility has no record of an annual fire inspection being completed for 2023.
Plan of Correction:	What Has Been Done to Correct? Appropriate fire official contacted by maintenance director How Will Recurrence Be Prevented? Annual fire inspection to be completed as to comply with the Virginia Statewide Fire Prevention Code. Person Responsible: Maintenance Director or designee