VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Front Royal
600 Mount View Street
Front royal, VA 22630
(540) 636-2800

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: Oct. 7, 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 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

The information found in this renewal inspection will be reviewed by the licensing administrator. The facility will be notified by mail regarding their license status. An unannounced renewal inspection was conducted by two LIs on 10/07/2019 from approximately 9:00am until 2:30pm. There were 77 residents in care; 45 residents in AL and 33 residents in the secured unit. All required postings were current, as were related drills. The facility was clean and free from any foul odors. Licenses and certifications were reviewed. Criminal history reports were reviewed. Medication administration records were reviewed for a selected number of residents. Ten resident, one discharge and six staff files were reviewed. Selected portions of two additional residents and six staff were also reviewed. There was one violation during this renewal inspection. Details of non-compliance can be viewed in the violation notice of this report. If you have any questions, please contact the licensing inspector at (540) 332-2330 or email the licensing inspector at rhonda.whitmer@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-930-D
Description:	Based upon review of residents' records, the facility failed to ensure the inability to use the call bell system is identified on the resident's Individualized Service Plan (ISP). EVIDENCE: The ISPs for residents G, H, I, J, and K did not identify their inability to use the call bell system due to having a diagnoses of a serious cognitive impairment.
Plan of Correction:	The ISPs for Resident G, H, I, J, and K were updated to reflect residents assessed needs. The ISPs of all other residents were reviewed to ensure compliance. The Executive Director, Resident Care Director, or designee will determine the ability or inability of the resident to use the call bell system at time of admission, annually, or if there is a change in the resident condition. Executive Director will review the Preliminary ISP on the date of admission. Executive Director will complete random monthly audit of a minimum of 5 Comprehensive ISPs to ensure ongoing compliance.