VIRGINIA DEPARTMENT OF SOCIAL SERVICES

COMMONWEALTH SENIOR LIVING AT HAMPTON
1030 TOPPING LANE
Hampton, VA 23666
(757) 826-3728

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: April 22, 2019

Complaint Related: No

Areas Reviewed:

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

Comments:

An unannounced monitoring inspection was conducted by the Licensing Inspector from the Eastern Regional Office on 04-22-2019 from 10:42 AM to 1:32 PM. There were 89 residents in care at the time of the inspection. LI conducted tour of the special care units and reviewed video footage regarding an incident report that was received. 3 resident records and 1 staff record were reviewed, and interviews were conducted with staff. The facility received violations "under" Buildings and Grounds and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. The areas of non-compliance were discussed with the Administrator throughout the inspection and during the exit interview. 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 06-08-2019. 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 #:	22VAC40-73-1180-B
Description:	Based on observation, record review, and interview, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects should be inaccessible to the resident except under staff supervision. Evidence: 1. On 04-17-2019, an incident report was received form the facility via e-mail stating, ?Resident #1 was observed drinking from a bottle of Acetone.? The date and time of the incident was 04-17-2019 at 2:30 PM. 2. During the inspection on 04-22-2019, staff #1 provided video footage of the incident dated 04-17-2019 which occurred on the women?s special care unit (SCU). Video footage was observed which revealed: staff #2 and staff #3 were conducting a nail painting activity in the dining room; staff #2 was sitting at a table with resident #1; at 2:39 PM staff #2 gets up from the table and walks away leaving resident #1 out of sight; staff #2 left a bottle of Acetone unattended on the table with resident #1 who is observed sitting alone; staff #3 is observed sitting at another table behind resident #1, however staff #3?s back was turned away from resident #1; at 2:40 PM resident #1 grabbed the bottle of acetone and put it in between her legs; staff #2 then returned to the dining room, however, staff #2 did not retrieve the bottle of acetone from resident #1; staff #2 is then observed walking around the dining room to interact with other residents; at 2:42 PM staff #3 observed resident #1 having the bottle of Acetone and retrieved the bottle from the resident. 3. During record review, the med aide to med aide communication log dated 04-17-2019 stated ?Resident has been sent to the hospital. Resident ingested Acetone.? In addition, staff #2 received a ?Counseling/Disciplinary Notice? on 04-17-2019 which stated ?staff #2 is in violation of a mistake made due to carelessness or failure to get necessary instructions. On Wednesday, April 17, 2019, staff #2 accidentally left a bottle of acetone unattended in the women?s MC dining room during an activity. A resident (resident #1) picked up the bottle and held it between her legs?? 4. On 04-22-2019, during the tour of the men?s and women?s SCU with staff #4, an oil diffuser located in the men?s sitting area and an oil diffuser near the women?s dining area were observed. The oil diffusers were turned on and contained water and essential oils. 5. During interview, staff #1 acknowledged the oil diffusers were located in the men?s and women?s SCU and stated that the oils are ?organic?.
Plan of Correction:	Executive Director counseled and Reeducated staff #2 and staff #3 on resident safety, oversight, and removal of any harmful material or objects during activities. Staff In-serviced on proper Handling and Removing of any harmful material and or objects for resident safety. RCD, ARCD, and or designee (RMA Supervisor or LPN Supervisor) will monitor for continued regulatory compliance. Diffusers were removed during Monitoring visit.
Standard #:	22VAC40-73-930-D
Description:	Based on record review and interview, the facility failed to ensure once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff should make rounds no less often than every two hours. Evidence: 1. During the inspection, staff #4 provided documentation of the two-hour rounds check log ?SM Mens Resident Rounds? for the men?s special care unit. The rounds during the 11:00 PM to 7:00 AM shift did not include the staff initials to indicate that a 2 hour check was completed: a. On 04-15-2019, the last round conducted by staff was at 2:00 AM. The 4:00 AM and 6:00 AM rounds were left blank. b. On 04-17-2019, the last round conducted by staff was at 12:00 AM. The 2:00 AM, 4:00 AM, and 6:00AM rounds were left blank. c. On 04-18-2019, the last round conducted by staff was at 5:00 AM. The 7:00 AM round was left blank. 2. Staff #1 provided a copy of the facility?s ?Resident Two Hour Round Check (02/01/2019)? policy which states ?All residents residing in the Sweet Memory Neighborhood shall be checked on every 2 hours using the Two-Hour Round Check Log. The Caregiver should physically see each resident and complete the log sheet to verify that the two-hour round was conducted?? 3. During interview, staff #1 and staff #4 acknowledged the aforementioned hourly rounds were missing.
Plan of Correction:	Staff in-serviced on proper completion of 2 hour round log on Memory care neighborhoods. RCD, ARCD, and or designee will review the log books daily to assure accurate recording of rounds. RCD. or designee, will complete log audit to ensure compliance with this regulation.