VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at the Eastern Shore
23610 North Street
Onancock, VA 23417
(757) 787-4343

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Aug. 15, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

An inspection was conducted on August 15, 2019 by two representatives from the Eastern Regional Office to inspect and measure the new safe, secure environment (memory care unit). The inspection was conducted from 10:27 AM until 3:13 PM. There were 59 residents in care, to include 11 residents in the current safe, secure environment. No residents were in care in the new unit. During the inspection a tour of the new safe, secure environment and the secured courtyard was conducted. Eight resident (8) rooms were measured to determine compliance with the regulations for licensed assisted living facilities. This new unit will have 18 resident rooms, a dining room, two living room areas, 2 spa bathrooms and an activity room. Water temperatures were tested and were within range. Emergency phone numbers posted by phone at nurse?s station. Furniture to be provided by facility or family as requested. Doors secured with mag lock and will unlock with staff key and/or fire alarm. Signaling device and call system consists of a call bell that rings to facility issued staff cellphones, which identifies the location/room number of the call bell. These were tested during the inspection. Spa bathrooms will be assigned and labeled.The current memory care unit to be closed after residents move. License capacity to remain at 80. The facility is currently undergoing renovations and enhancements throughout the building. Violations were cited in the areas of Buildings and Grounds and Emergency Preparedness and were discussed with the Executive Director during the exit meeting. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice. The plan of correction should indicate how the violation will be or has been corrected. It should include 1. Step(s) to correct the noncompliance with the standard(s) 2. Measures to prevent re-occurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative action(s).

Violations:

Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview, the facility failed to ensure the interior of the building was maintained clean and in good repair. Evidence: 1.During a tour of the renovated new ?Sweet Memories?memory care unit with staff #1, Licensing Inspector observed the following: a. The floor tile in room 506 was missing a triangular section on the corner of the floor slat behind the bathroom door. b.In room 512, the floor was missing a section of the floor slat approximately 12 inches long, in the front corner of the room near the closet. c.The spa bathroom across from rooms 503 and 505 had white dust where the tile meets the wall by the bathtub, all around the surface of the tile. d.In room 513, the HVAC/ Air conditioning unit?s left panel door was loose and was missing the left screw. e. In room 516, the fluorescent light cover had visible insects and dust in it. 2.Staff #1 acknowledge the areas mentioned.
Plan of Correction:	Areas of concern were cleaned and repaired. Remaining areas were inspected to ensure that there were no additional cleaning or repair needs. Housekeeping cleaning schedule implemented and Maintenance and Housekeeping associates in-serviced on cleaning needs and repair. Direct care associates and housekeeping associates re-inserviced on completing maintenance repair requests when items are in need of repair. Administrator, Maintenance Director, Resident Care Director, Assistant Resident Care Director, or designee will round a minimum of 2 times per day to ensure continued compliance.
Standard #:	22VAC40-73-870-B
Description:	Based on observation and interview, the facility failed to ensure the building was free from foul odors. Evidence: 1. During a tour of the new renovated "Sweet Memories" memory care unit with staff #1, the closet in room 512 and 516 had a pungent and foul urine odor. 2. Staff #1 acknowledged the odor in rooms 512 and 516.
Plan of Correction:	The floor tiles were replaced and the rooms scheduled to have the dry wall and the insulation in the closets replaced to ensure the odor is eliminated. The studs will be treated with TSP, which is an odor neutralizer. Maintenance Director will continue to round in the community daily and Executive Director will round in the community a minimum of 2 times per day to ensure continued compliance.
Standard #:	22VAC40-73-960-B
Description:	Based on observation and interview, the facility failed to ensure the fire and emergency evacuation drawing include the areas of refuge, assembly areas, and location of phones. Evidence: 1. The Fire and evacuation drawing posted in the new ?Sweet Memories? memory care unit did not include the areas of refuge, assembly areas, and location of phones. 2. Staff #1 acknowledged the missing information on the fire and evacuation drawing.
Plan of Correction:	Fire and Evacuation Drawings were updated to include the areas of refuge, assembly areas, and location of phones. The Maintenance Director will review and update this drawing as necessary, for continued accuracy of information.