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: Jan. 4, 2021 , Jan. 5, 2021 and Jan. 6, 2021

Complaint Related: No

Areas Reviewed:

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 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 1/4/2021 and concluded on 1/6/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 57. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, staff schedules, Health Care Oversight, Fire Inspection, Health Department Inspection, Fire and Emergency drills, and Dietitian Oversight submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review and discussion, the facility failed to ensure the physical examination report documented the descriptions of the person?s reactions to known allergies. Evidence: 1. Resident #2?s physical examination report dated 12/9/2020 did not document a description of reactions to known allergies: latex, natural rubber, and Penicillin. 2. Staff #5 acknowledged Resident #2?s physical examination report dated 12/9/2020 did not include the aforementioned information.
Plan of Correction:	RCD is auditing all H&Ps for reactions to identified allergies. Addendum has been added to all current residents indicating allergies and reactions to those allergies. RCD & ED will review all physical examination reports upon admission to ensure that reactions to all allergies are listed and indicated on H&P.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and discussion, the facility failed to ensure the Individualized Service Plan (ISP) included description of identified needs based upon the physical examination and/or Uniform Assessment Instrument (UAI). Evidence: 1. Resident #1?s physical examination report dated 8/31/2020 documented a ?regular diet-no salt? diet. Additionally, the resident?s record did not include documentation indicating that the resident?s diet was changed to remove ?no added salt?. a. Resident #1?s ISP dated 10/8/2020 did not include the ?regular diet-no salt? diet that was documented on the physical examination report. b. Staff #5 acknowledged Resident #1?s ISP dated 10/8/2020 did not include the ?regular diet-no salt? diet. Additionally, Staff #5 did not provide a physician?s order that changed the resident?s diet. c. Resident #1?s UAI dated 8/31/2020 documented the resident needs mechanical help and human help supervision with bathing; however, Resident #1?s ISP dated 10/8/2020 did not document the mechanical help needed for bathing. d. Staff #5 acknowledged Resident #1?s ISP dated 10/8/2020 did not document the mechanical help needed for bathing. 2. Resident #3?s physical examination report dated 8/12/2020 documented a ?regular diet-easy to chew? diet. Additionally, the resident?s record did not include documentation indicating that the resident?s diet was changed to remove ?easy to chew?. a. Resident #3?s ISP dated 9/17/2020 did not include the ?regular diet-easy to chew? diet that was documented on the physical examination report. b. Staff #5 acknowledged Resident #3?s ISP dated 9/17/2020 did not include the ?regular diet-easy to chew? diet. Additionally, Staff #5 did not provide a physician?s order that changed the resident?s diet.
Plan of Correction:	RCD made correction to ISP to reflect "no added salt" diet order. RCD made correction to ISP to reflect correct functional status regarding bathing assistance. RCS added "easy to chew" to IPS as indicated on admission orders. ED &RCD will review ISPs to ensure correct diet and functional status is documented on ISP.