VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Williamsburg
236 Commons Way
Williamsburg, VA 23185
(757) 564-4433

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: April 2, 2019

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 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 32.1 Reported by persons other than physicians 63.2 Protection of adults and reporting. 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 renewal inspection was conducted on 4-2-19 with an inspector from the Eastern Regional Office and the Peninsula Licensing Office. (arrival 08:31 am/ departure 7:40 pm). The facility census was 35. A medication observation was conducted on the special care unit and the mixed population unit. Meals and activity were observed on the special care unit. There were no attendees for the morning exercise activity on the mixed population section. Staff and resident interviews were conducted, staff and resident records were reviewed, water temperature monitored, medication cart checked. An exit interview was conducted with the administrator and two assistants. The administrator signed the acknowledgement document. Comment: The inspector suggest the facility have a system to determine staff training needs and time for completion, also reminded administrator of the need to follow-up with resident's physician on recommendations provided by the pharmacy and nutritional review. Facility should describe the service and frequency of services to be provided. The facility should periodically check the temperature in the building, particularly in the common area where residents gather. Inspector requested administrator clarify facility's acceptance of auxiliary grants residents, administrator stated two rooms were allocated for such service. Please complete the 'Plan of Correction' and 'Date to be Corrected' for each violation cited on the violation notice and return it to me within 10 calendar days from today. 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. Plan of correction is due within 10 days (4-22-19)

Violations:

Standard #:	22VAC40-73-1140-B
Description:	Based on record review, document review and staff interview, the facility failed to ensure within four months of the starting date of employment, direct care staff shall attend at least 10 hours of training in cognitive impairment that meets the requirements in the standard. Evidence: 1. On 4-2-19 during a review of the sample staff records with staff #6, staff #11's record did not have documentation of 10 hours of cognitive training within 4 months of date of hire. A review of the printed copy of the facility's training document with staff #6 , staff #11's record noted 8.25 hours of cognitive training for staff who work the safe, secure environment unit. Staff #11's record noted 12-10-18 as staff's date of hire. 2. A review of staff #13's record with staff #6, revealed a review of the facility's training document noted 6.00 hours of cognitive training. Staff #13's record noted 8-20-18 as staff's date of hire. 3. Staff #5 acknowledged staff #11 and #13 did not have the required number of hours of training within 4 months of date of hire.
Plan of Correction:	Staff #11, #13, #5 completed cognitive training by 4/30/19. The BOM or designee will audit and track all staff members for continued compliance. Date of compliance 4/30/19
Standard #:	22VAC40-73-260-A
Description:	Based on record review, document review and staff interview, the facility failed to ensure each direct care staff member who does not have current certification in first aide from the approve source shall receive certification in first aid within 60 days of employment. Evidence: 1. On 4-2-19 during the inspector's review of staff records with staff #6, the following current staff did not have documentation of first aid within 60 days of hire: (a) staff #10, date of hire noted 4-13-18, (b) staff #11, date of hire noted 12-10-18, and staff #12, date of hire noted 12-6-18. 2. Staff #1, #2 and #6 acknowledged on 4-2-19 direct care staff did not have verification of first aid. 3. Staff #1 forwarded first aid information to inspector per request on 4-3-19 and 4-4-19. 4. On 4-11-19, per telephone interview with staff #1, #2 and #5, staff acknowledged, staff #10, #11 and #12 did not have documentation of first aid as of the inspection date, 4-2-19.
Plan of Correction:	Staff #10, #11 and #12 completed First Aid training on 4/18/19. The BOM or designee will audit and track all staff members for continued compliance. Date of compliance: 4/30/19
Standard #:	22VAC40-73-440-D
Description:	Based on record review, observation, and interview, the facility failed to ensure the assisted living facility completed the uniform assessment instrument (UAI) as required for two of eight resident's record reviewed. Evidence: 1. The inspector observed staff #7 feed resident #1 during breakfast and lunch. A family member was observed feeding the resident the dinner meal around 5:45 p.m. on the day of the inspection, 4-2-19. 2. During interview with staff #3 and staff #7, the inspector was told the resident needed assistance with eating. 3. While reviewing resident #1's UAI with staff #2, the inspector found resident #1's dependency in eating had not been addressed on the resident's UAI dated 1-18-19. 4. During the inspector's review of resident #5's UAI dated 6-5-18, with staff #5, the resident had no dependency with activities of daily living (adl), semi-dependency noted. Further review of the UAI noted the resident was assessed at the assisted living level of care (dependent with two or more adls). 5. Staff #2 acknowledged resident #1's information was not addressed. 6. Staff #5 acknowledged resident #5's level of care was not corrected noted.
Plan of Correction:	Resident #1 UAI updated to reflect the amount of assistance required for eating. Resident #5 UAI was updated to reflect residential level of care. The ED, AED, RCD or designee will audit at least five current residents' UAIs weekly for 8 weeks to ensure continued compliance. Date of compliance 4/30/19
Standard #:	22VAC40-73-440-G
Description:	Based on observation, record review and staff interview, the facility failed to ensure the uniform assessment instrument (UAI) was updated when there was a significant change in a resident's condition for one of eight resident record reviewed. Evidence: 1. While reviewing resident #2's record with staff #1 and #2, the inspector found the resident's UAI dated 11-9-18 had the resident assessed as semi-dependent in behaviors. Documentation on file reviewed by the inspector indicated a significant change in the resident's behavior had occurred and the UAI had not been updated to reflect the change. 2. The inspector reviewed a staff note dated 11-11-18, indicating the resident was aggressive with other residents and her family on 12-30-18. The resident's doctor was notified about the resident's combative behavior. The inspector also reviewed a staff behavior monitoring chart in resident #2's record documenting the resident's behavior. In January 2019, thirteen (13) behavioral incidents were documented. The behavior monitoring chart included yelling at staff, family, or other resident, pushing, screaming, and smacking at her spouse. 3. The resident was observed with sitter services on the day of the inspection, 4-2-19. The sitter was present to help monitor resident #2's behavior. The sitter services were initiated in March 2019 along and mental health services were also initiated. 4. During the inspector's interview with staff #1, and #2, staff spoke of the resident's combative yelling, and exit seeking behaviors. 5. During the inspection, the inspectors observed resident #2's exit seeking behavior and yelling during an episode in the afternoon. Resident was observed trying to exit the side door in the common area that went to the enclosed patio area. 6. The inspectors reviewed a facility notice of discharge for resident #2, dated 3-25-19. The justification cited behaviors as the reason for resident #2's pending discharge. 7. Staff #2 acknowledged resident #2's UAI was not updated.
Plan of Correction:	Resident #2 UAI updated to reflect total dependency in behaviors. The ED, AED, RCD or designee will audit five current residents' UAIs weekly for 8 weeks to ensure continued compliance with any significant changes that need to be reflected on the UAI. Date of compliance 4/30/19
Standard #:	22VAC40-73-450-C
Description:	Based on observation, record review, document review and staff interview, the facility failed to ensure the individualized service plan (IPS) include all of the resident's assessed needs for one of eight records reviewed. Evidence: 1. On 4-2-19 during the review of the sample resident's record with staff #5, resident #5's uniformed assessment instrument (UAI) dated 12-3-18 and 6-5-18 indicated wheeling not performed, however, resident #5's ISP signed by resident 6-26-18 did not indicated what services provided. 2. The inspector observed the resident during the morning medication pass, and resident is able to wheel self, if needed. Further review of the UAI indicate stairclimbing assessed as human help/supervision, however, the ISP indicated resident required mechanical help/human help/supervision with staff to provide stand by assist. The ISP did not indicate what mechanical help was needed. 3. In addition, mobility was assessed on the UAI as mechanical help; however, the ISP did not indicate the mechanical help needed. 4. Staff #2 and #5 acknowledged on 4-2-19, the discrepancy between the information on resident #5's UAI and the ISP.
Plan of Correction:	Resident #5 ISP was updated to reflect mechanical assistance required for mobility and to indicate that the resident does not require assistance with wheeling. The ED, AED, RCD or designee will audit at least five current residents' ISPs weekly for 8 weeks to ensure continued compliance. Date of compliance 4/30/19
Standard #:	22VAC40-73-450-F
Description:	Based on record review, document review and staff interview, the facility failed to ensure the individualized service plan (ISP) was updated as the condition of the resident changed. The update shall be performed by a qualified staff person and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other person. Evidence: 1. The service from the sitter observed in place during the inspection on 4-2-19 was also not on the resident #2's ISP. 2. During interview with the sitter (#9), the inspector was informed sitter services were provided 24 hours daily. The sitter's duties include sitting outside the resident's room, resident does not like the sitters in the room); sitter is also required to follow resident #2 at a distance whenever resident leaves the room, sitters are to provide prompting or cueing to the resident should the resident come out of the room inappropriately dress or wanders into another resident's room; redirecting resident #2 when exit seeking (this was observed during the inspection) and offering socialization for resident #2. 3. Staff #2 acknowledged the ISP had not been updated to reflect the change.
Plan of Correction:	Resident #2 ISP was updated to reflect 1/2 cup dairy daily and personal sitter services. The ED, AED. RCD or designee will audit at least five current residents' ISPs weekly for 8 eight weeks to ensure continue compliance.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, document review, record review and staff interview, the facility failed to ensure the facility implemented a written plan of medication management. The facility's medication plan shall address procedures for administering medication and shall include: methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order. Evidence: 1. During a review of physician orders following the medication observation with staff #3, the inspector observed in the medication cart, resident #1's Prax lotion. The lotion to be administered as needed (prn) to arms and back, per hospice order dated 3-14-19. As of 9:15 a.m. on the day of the inspection, 4-2-19, and medication observation with staff #3, the medication had not been transcribed to resident #1's April 2019 MAR. 2. Staff #3 confirmed the medication had not been transcribed to resident #1's April 2019 MAR. 3. Staff #3 checked resident #1's March 2019 MAR and also confirmed that the Prax lotion was not on the March 2019's MAR. Later during the inspector's interview with staff #2, it was confirmed that the medication, Prax lotion, was not on March 2019's MAR. The Prax lotion was added to the April 2019's MAR on the afternoon of 4-2-19.
Plan of Correction:	Resident #1's medicated lotion was updated on the electronic MAR. The RCD or nurse designee will receive and review all new medications orders to ensure all orders are transposed to the electronic MAR within the acceptable time frame and review the electronic system at least daily for four weeks to ensure continued compliance. Date of compliance: 4/30/19
Standard #:	22VAC40-73-680-D
Description:	Based on medication observation, document review, record review and staff interview, the facility failed to ensure all medications were administered in accordance with the physician's or other prescriber's instruction and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. During the medication observation with staff #3, the inspector observed resident #1 received Carvedilol 3.125 mg twice daily, (9 am and 5 pm); instruction indicated to be given with food per the admission orders dated 2-7-19. The medication was observed given in the dayroom at 9:15 am with only water. 2. Later during the inspector's interview with evening staff #8, staff stated resident #1's Carvedilol 3.125mg was given before the resident came to dinner. Staff #8 stated, dinner on the special care unit begins at 5:30 pm.
Plan of Correction:	RMAs will be in-serviced on medication administration. The RCD or nurse designee will audit and track all staff members for continued compliance.