VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Memory Care at Chesapeake
130 Great Bridge Blvd.
Chesapeake, VA 23320
(757) 436-2109

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: April 29, 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 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Technical Assistance:

Emergency Placement

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 04/29/2024 from 8:17 am to 2:48 pm. 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: 66 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: 4 Observations by licensing inspector: Breakfast, Lunch and an activity were observed. A medication pass observation was completed for three 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. 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 #:	22VAC40-73-40-C
Description:	Based on the onsite record review the facility failed to ensure any person required to obtain a criminal history report shall be ineligible for employment if the report contains convictions of barrier crimes. Evidence: 1. Staff #5, date of hire 11/07/23, criminal record report contains two convictions for barrier crimes (18.2-57 and 18.2-51.2).
Plan of Correction:	Staff #5 is no longer employed with CSL. Business Office Manager and/or designee to review all background checks and barrier crime list prior to start date and ongoing.
Standard #:	22VAC40-73-260-A
Description:	Based on the record review the facility failed to ensure each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment. Evidence: 1. The record for staff #1, date of hire 07/26/23, contains a first aid certification completed on 04/29/24. The staff record did not contain a first aid certification completed within 60 days of employment.
Plan of Correction:	Staff #1 first aid certification is now on file dated for 4/29/24. Business Office Manager and/or designee will randomly review files monthly to ensure all first aid certifications are on file within the prospective timeline.
Standard #:	22VAC40-73-320-A
Description:	Based on the record review the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. Evidence: 1. The record for resident #3, admitted 04/19/24, contains a physical examination dated as completed on 02/28/24, which is more than 30 days prior to the resident?s admission to the facility.
Plan of Correction:	Resident Care Director, Assistant Resident Care Director and Executive Director to review all history and physicals prior to admission to community to ensure completion within 30 days prior to move in.
Standard #:	22VAC40-73-450-E
Description:	The individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative. Evidence: 1. Resident?s #2 ISP dated 10/30/23 did not include the resident or legal representative signature. 2. Resident?s #5 ISP dated 11/27/23 did not include the resident or legal representative signature. 3. Resident?s #6 ISP dated 04/04/24 did not include the resident?s or legal representative signature.
Plan of Correction:	Resident #2, #5 and # 6 ISP to be signed by 05/31/2024. Resident Care Director, Assistant Resident Care Director and/or designee will randomly audit resident's ISP?s to ensure timely signature of ISP?s. If not signed by legal representative, documentation to be provided for justification of why ISP not signed.
Standard #:	22VAC40-73-660-A
Description:	Based on observation, it was determined that the facility did not ensure that medications shall be stored in a manner consistent with current standards of practice and the storage area shall be locked and the individual responsible for medication administration shall keep the keys to the storage area on his person. Evidence: 1. During a tour of the facility with staff #6, the medication cart was observed to be unlocked and unstaffed.
Plan of Correction:	Inservice to be provided to discuss the importance of medication cart being locked and supervised. Resident Care Director, Assistant Resident Care Director and/or designee to perform random cart audits weekly to ensure that medication cart is locked and monitored by registered medication aide when in use.