VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at King's Grant House
440 North Lynnhaven Road
Va. beach, VA 23452
(757) 431-8825

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: May 3, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced complaint inspection was conducted by the Licensing Inspector from the Eastern Regional Office on 05-03-2019 from 8:10 AM to 2:41 PM. There were 66 residents in care at the time of the inspection. The complaint was alleging concerns regarding staffing on the special care unit and personnel. A tour of the memory care facility was conducted, 2 staff records were reviewed, interviews were conducted with staff, and staff schedules and time sheets were reviewed. LI discussed staffing on the special care unit with the Administrator during the inspection. The facility received a violation "under" Additional Requirements for Facilities for Adults with Serious Cognitive Impairments . The violation was reviewed with the Administrator throughout the inspection. Based on the information reviewed during this inspection a portion of the complaint was found to be valid. Please complete the -Plan of Correction- for each violation cited on the violation notice and return it to me within 10 calendar days from today, on 05-30-2019. You will need to specify how the violation will be or has been corrected. Just writing the word corrected is not acceptable. Your plan of correction must include: 1. steps to correct the noncompliance 2. measures to prevent reoccurrences 3. person(s) responsible for implementing and monitoring each step of the corrective measures and / or the preventative measure.

Violations:

Standard #:	22VAC40-73-1130-A
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure when 20 or fewer residents are present, at least two direct care staff members are awake and on duty at all times in each special care unit who shall be responsible for the care and supervision of the residents. For every additional 10 residents, or portion thereof, at least one more direct care staff member shall be awake and on duty in the unit. Evidence: 1. Staff #1 provided the Licensing Inspector with a copy of the staff working schedules and the staff time sheets labeled "Timecard Editor" dated 04-01-2019 and 04-29-2019, which revealed the facility did not have the required number of direct care staff on the ?Sweet Memories? special care unit (SCU) during the 10:45PM to 7:15AM shift. a. On 04-01-2019, the total census for the facility was 69, to include 26 residents in SCU. The minimum required staffing on the SCU was 3 direct care staff. The staff work schedule dated 04-01-2018 indicated 4 direct care staff were scheduled to work on the assisted living unit (AL) and SCU during the 10:45PM to 7:15AM shift. The ?Timecard Editor? dated 04-02-2019 (for 04-01-2019) revealed 4 direct care staff worked during the 10:45PM to 7:15AM shift (staff #2, #3, #4, and #5). Upon further review of the ?Timecard Editor? 2 of the 4 staff were on break at the same time (staff #2 from 3:14AM to 3:49AM and staff #5 from 3:12AM to 3:39AM) leaving 2 direct care staff on duty in the SCU and AL area of the facility. b. On 04-29-2019, the total census for the facility was 93; to include 25 residents in the SCU. The minimum required staffing on the SCU was 3 direct care staff. The staff work schedule dated 04-29-2019 indicated 4 direct care staff were scheduled to work during the 10:45 PM to 7:15 AM shift. The "Timecard Editor" dated 04-30-2019 (for 04-29-2019) revealed 5 direct care staff worked during the 10:45PM to 7:15AM shift (staff #2, #3, #5, #6, and #7). Upon further review of the "Timecard Editor" 3 of the 5 staff were on break at the same time (staff #2 from 3:33AM to 4:01AM, and staff #3 from 3:54AM to 4:19AM, and staff #7 from 3:17AM to 3:47AM) leaving 2 direct care staff on duty in the SCU and AL area of the facility. In addition 2 of the 5 staff were also on break at the same time (staff #6 from 2:59AM to 3:30AM and staff #5 from 2:53AM to 3:20AM) leaving 3 direct care staff on duty in the SCU and AL area of the facility. 2. During interview, staff #1 indicted there were no additional staff that worked during the 10:45PM to 7:15AM shift on 04-01-2019 and 04-29-2019. Staff #1 acknowledged the facility did not have the required number of staff on duty during the aforementioned break times.
Plan of Correction:	Re-in-serviced Executive Director, Resident Care Director, Assistant Resident Care Director and all Direct Care Staff on DSS regulation 1130-A Staffing for Special Care Unit. Assisted Living care aide will relieve special care unit staff for all breaks. Executive Director, Resident Care Director or designee to monitor daily staffing to ensure staff are fully scheduled to meet the needs of the residents.