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: July 25, 2024

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 07/25/24 from 9:33 am to 12:45 pm. 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 07/01/2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 65 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: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: A review of the facility?s policy and procedures was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on the record review the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admissions. Evidence: 1. The record for resident #3, admission date 12/07/23, contains a preliminary plan of care dated 12/07/23. Resident?s #3 ISP is dated as completed on 02/10/24. The resident?s record does not contain an ISP completed 30 days after the resident?s admission date of 12/07/23.
Plan of Correction:	What Has Been Done to Correct? Residents ISP unable to be completed due to resident having moved out. How Will Recurrence Be Prevented? Audit of ISP?s will be completed for all residents to ensure inactive ISP is current. ARCD/RCD will review Yardi daily for compliance. Person Responsible: ARCD / RCD / ED
Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on the record review the facility failed to implement a written plan for medication management to include: Methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. Evidence: 1. The facility?s medication management plan includes the following: ?shift counts are performed at the end of each shift or when the person responsible for medication changes.? 2. The facility?s ?Narcotic Shift Count? form did not include staff signatures for both the off going and oncoming shifts for the following dates and shifts: 06/04/24, 3-11 Shift. 06/04/24, 11-7 shift. 06/07/24, 11-3 shift. 06/20/24, 3-11 shift. 06/22/24, 7-3 shift. 06/23/24, 7-3 shift. 07/14/24, 3-11 shift. 07/17/24, 7-3 shift.
Plan of Correction:	What Has Been Done to Correct? Ongoing education and intermittent oversight of narcotic count by leadership. How Will Recurrence Be Prevented? Ongoing education and intermittent oversight of narcotic count by leadership. Educate all med-admin staff on CSL Policies VA12.113 and VA12.129, moving forward corrective action will be taken for all non-compliance. Person Responsible: ARCD / RCD / ED
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on the record review the facility failed to ensure the Medication Administration Record (MAR) shall include: For as needed (PRN) medications: symptoms for which medications was given, exact dosage given, and effectiveness. Evidence: Resident?s #3 ?Controlled Drug Record? documents the resident was given one tablet of Tramadol as a PRN on the dates of 04/09/24 and 04/13/24. Resident?s #3 MAR for April 2024 does not include documentation the resident was given Tramadol as a PRN on the dates of 04/09/24 and 04/13/24 and does not include symptoms for which the Tramadol was given and the effectiveness for the dates of 04/09/24 and 04/13/24.
Plan of Correction:	What Has Been Done to Correct? Ongoing education How Will Recurrence Be Prevented? Educate all med-admin staff on CSL Policies VA12.102, VA12.113 and VA12.129, moving forward corrective action will be taken for all non-compliance. Person Responsible: ARCD / RCD / ED