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. 16, 2021 and Dec. 21, 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 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 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 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced monitoring inspection was conducted on 12-16-2021. The facility administrator was present. The census was 58. A tour of the facility was conducted, medication observation pass conducted, activity reviewed, facility postings conducted, staff and resident record reviewed, water temperature conducted, signaling device reviewed, emergency supplies observed, reports from other entities reviewed, healthcare oversight document reviewed, first aid kits checked, staff and resident interviews conducted. A self-reported issue also reviewed with administrator and staff. Violations and questions were conducted throughout the inspection. An exit was conducted with the administrator on 12-26-21. A final exit was conducted on 12-21-21 and the Acknowledgement Form was sent via email. A final call regarding a violation was conducted on 12-27-21. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. POC due 1-6-2022.

Violations:

Standard #:	22VAC40-73-100-C-1
Description:	Based on observation and staff interviewed, the facility failed to ensure infection control procedures were implemented. Evidence: 1. On 12-16-21 during the medication observation check of the medication cart on the second floor with staff #8, resident #8?s glucometer inside the black pouch was labeled with resident #7?s name. 2. Staff #8, stated resident #7 does not have blood sugar checks and does not reside on the second floor. Staff confirmed the name on the glucometer was resident #7 not resident #8.
Plan of Correction:	What Has Been Done to Correct? Cart Audit checklist has been created for the RMA?s, ARCD and RCD. Each RMA will be re-in-serviced regarding the inspecting of his/her cart during their shift to ensure all items on the cart are labeled properly. Formal cart audits will be conducted at least 1x weekly by the RMA?s to ensure all residents personal machines are properly stored and labeled inside of the cart. How Will Recurrence Be Prevented? The Assistant Resident Care Director and/or Resident Care Director will conduct a monthly review of the submitted Cart Audit Forms to ensure audits are being completed. Person Responsible ARCD and RCD or Designee Due Date: 1/17/2022
Standard #:	22VAC40-73-40-A
Description:	Based on observation and staff interviewed, the facility to ensure any document required by the regulation to be posted shall be in at least a 12-point type or equivalent size, unless otherwise specified. Evidence: 1. On 12-16-21 during a tour of the facility with staff #1, the weekly menu posted in the dining room was less than 12-point type or equivalent size. 2. Staff #1 confirmed the menu?s font sized was not at least 12-point type.
Plan of Correction:	What Has Been Done to Correct? We have posted the resident menus in 12 pitch font size to ensure regulatory compliance How Will Recurrence Be Prevented? The Dining Services Director will check all menu postings, on a weekly basis to ensure proper font size. Person Responsible Dining Services Director or Designee D/2021ue Date: 12/16/2021
Standard #:	22VAC40-73-260-C
Description:	Based on observation and staff interviewed, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR, in conformance with subsections A and B of section 260 (First Aid and CPR certification), shall be posted in the facility so that the information is readily available to all staff at all times. The listing must indicate by staff person whether the certification is in first aide or CPR or both and must be kept up to date. Evidence: 1. On 12-16-21 during a tour of the facility the inspector inquired of staff #2 where the first and CPR listing of staff was posted. The area near the copier was visited, but the information was not posted there. The staff's break area was visited to determine if the document was posted there and it was not. 2. Staff #2 acknowledged the listing of staff certified in first aid and CPR was not posted and available when the inspector was touring the facility.
Plan of Correction:	What Has Been Done to Correct? An updated listing of all first aid and CPR certified staff has been posted on each floor and/or unit (in the staff breakroom and on each medication cart). How Will Recurrence Be Prevented? Each new staff member shall be informed during their Jumpstart(New Hire Orientation) of the location of the listing/information. Person Responsible: Business Office Manager, Assistant Resident Care Director and Resident Care Director or Designee Due Date: 12/16/2021
Standard #:	22VAC40-73-290-B
Description:	Based on observation and staff interviewed, the facility failed to ensure it posted the name of the current on-site person in charge, as provided for in the regulation, in a place in the facility that is conspicuous to the residents and to the public. Evidence: 1. On 12-16-21 upon entering the facility, the posting for the staff person in charge (SIC) was not available. The inspector inquired of staff #1 where the posting was. The staff and inspector went to the foyer area located at the front entrance and there was no listing of SIC. The inspector and staff #1 also checked the area where the concierge sits and check-in area, there was no posting in this area. 2. Staff #1 acknowledged the staff person in charge posting was not available when the inspector arrive at 8:45 a.m. on 12-16-21.
Plan of Correction:	What Has Been Done to Correct? We have placed a plaque on the desk of the Concierge as well as posted on the board in the entrance; indicating the manager-on-duty. How Will Recurrence Be Prevented? The concierge will ensure the name plates are changed/updated to reflect accurate information. A weekly list shall be placed in the informational frame located in the foya/entrance area of the community; visible to all residents and guest. Person Responsible: Concierge or Designee Due Date: 12/16/2021
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure all assessed needs were addressed on the resident?s individualized service plan (ISP). Evidence: 1. Resident #4?s uniformed assessment instrument (UAI) dated 12-15-21 documented dressing needs as mechanical help/human help/physical assistance. The ISP dated 12-15-21 documented staff assistance with dressing, but did not include a mechanical help device. 2. On 12-26-21, resident #6?s personal and social data form/ face sheet documented the resident?s allergy to Acetaminophen. Staff #2 stated the information would be reviewed for its accuracy. 3. Staff #2 acknowledged the Acetaminophen documented on resident #6?s personal and social data sheet was not documented on the resident?s ISP. Staff also acknowledged no mechanical device was documented for dressing assistance for resident #4. 4. Staff #1 acknowledged during the final exit meeting, all assessed needs for residents were not addressed on resident #4 and #6?s ISP.
Plan of Correction:	What Has Been Done to Correct? The Executive Director, Assistant Resident Care Director and Resident Care Director are reviewing all ISP?s to ensure all resident needs are properly and accurately addressed. How Will Recurrence Be Prevented? The Resident Care Director will review at least three (3) ISP?s; weekly to ensure accurate documentation and care rendered to each resident reflects such. Person Responsible: Director of Resident Care or Designee Due Date: 1/17/2022
Standard #:	22VAC40-73-940-A
Description:	Based on document reviewed, collateral interview, and staff interviewed, the facility failed to ensure it complied with the Virginia Statewide Fire Prevention code (13 VAC 5-51) as determined by at least annual inspection by the appropriate fire official. Evidence: 1. On 12-16-21, the fire inspection document presented to the inspector was dated 1-9-20. 2. On 12-21-21, the violation was reviewed with the staff #1 during the final exit interview. 3. On 12-27-21, a collateral interview was conducted and it was determined, the facility?s last fire inspection was conducted on 12-10-19, and the re-inspection was conducted on 1-9-20. 4. On 12-27-21, the licensing inspector contacted staff #1 to inform the violation for the annual inspection would be cited.
Plan of Correction:	What Has Been Done to Correct? The Maintenance Director has scheduled the annual review from the local fire department. How Will Recurrence Be Prevented? On an annual basis, the Maintenance Director will reach out to the local fire department (October), to schedule a renewal inspection. Person Responsible: Maintenance Director or Designee Due Date: 1/19/2022
Standard #:	22VAC40-73-960-B
Description:	Based on observation and staff interview, the facility failed to ensure the fire and emergency evacuation drawing posted contained all required information. Evidence: 1. On 12-16-21 during a tour of the facility with staff #8, the evacuation posting on the first floor on the wall near the maintenance director?s office and second floor posting near the elevator did not include the telephone locations and the fire alarm boxes. 2. On 12-21-21 during the final exit interview, staff #1 acknowledged the emergency evacuation drawings did not include all required information.
Plan of Correction:	What Has Been Done to Correct? The Maintenance Director will ensure all telephone locations and fire alarm locations are clearly indicated on the wall-posted emergency evacuation plans which are posted throughout the community/facility. How Will Recurrence Be Prevented? The Executive Director will monitor during daily walk-a-bouts/rounding in the community Person Responsible: Executive Director or Designee Due Date: 12/16/2021
Standard #:	22VAC40-73-960-C
Description:	Based on observation and staff interviewed, the facility failed to ensure the telephone numbers for the fire department, rescue squad or ambulance, police and Poison Control Center was posted by each telephone shown on the fire and emergency evacuation plan. Evidence: 1. On 12-16-21 during a tour of the second floor with staff #8, the inspector inquired of staff where the telephones were located as this information was not listed on the evacuation postings in the hallway. Staff and the inspector checked the telephone on the second floor, but there were no telephone numbers listed. The nursing station area was checked, the cabinets and binders were also checked for the telephone numbers. The third floor nursing area was also checked and the telephone numbers were not available. 2. Staff #1 acknowledged the emergency telephone numbers for police, ambulance, rescue squad and Poison Control Center was not posted and or listed by the telephone on the second and third floor.
Plan of Correction:	What Has Been Done to Correct? The Maintenance Director and Resident Care Director will ensure that all required emergency telephone numbers are placed in a protective cover, next to each posted fire and emergency evacuation plan in the community. In addition, a list will be kept inside of each medication cart for easy/immediate access when needed. How Will Recurrence Be Prevented? The Medication Aide, Assistant Director of Resident Care and Resident Care Director will ensure the list is always available and up-to-date on each medication cart ? on a monthly basis Person Responsible: Maintenance Director and Resident Care Director or Designee Due Date: 1/21/2022