VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Kilmarnock
460 S. Main Street
Kilmarnock, VA 22482
(804) 435-9896

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Oct. 9, 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

Comments:

An unannounced renewal inspection was initiated at the facility on 09/16/2019 and concluded on 09/30/2019. At the time of entrance on 09/16/20, the facility's Administrator offered 56 residents in care. Based on the census offered and other information discussed during the entrance interview a sampling of six resident records, four staff and other facility records were reviewed for compliance. The facility reported new and discharged residents since the last onsite inspection as well as new staff hires. Resident and staff interviews were conducted. Observation of the physical plant was conducted throughout the two day inspection. Residents were observed during meal times and activities. A noon time medication administration pass was observed on 09/30/2019. During the exit interview conducted on 09/16/2019 the facility Administrator was informed that the photographs taken during the renewal inspection would be forwarded to the facility. The noncompliance is identified in this report. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the Inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Please contact me at (804)662-9774 or by e-mail at Angela.r.reaves@dss.virginia.gov if you have any questions. The inspection conducted on 09/30/2019 was conducted between the approximate hours of 11:05a.m until 1:45p.m. The inspection conducted on 09/30/2019 was conducted between the approximate hours of 10:00a.m until 1:46p.m

Violations:

Standard #:	22VAC40-73-450-F
Description:	Based on the review of facility records with the facility Administrator on 09/30/2019, the facility failed to ensure that a resident's Individualized Service Plan (ISP) was updated as the condition of the resident changed. Evidence: Resident # 3-Documented date of admission 02/13/2011 The resident's 05/22/2019 ISP that was submitted for the inspector's review had a hand written entry that noted "Keep aggressive residents seperated". Facility staff stated during interviews that resident #3 was usually agitated by loud noises and aggressive residents but the facility did not care plan their knowledge of the resident's known triggers in a manner that specifically identified all required elements of developing a resident's ISP.
Plan of Correction:	FACILITY RESPONSE- "The Resident Care Director or designee will ensure that each ISP is reviewed and updated annually or if there is a change in the resident condition. Resident # 3 ISP was updated to reflect assessed needs including known triggers and individualized interventions. The ISPs of other residents were reviewed to ensure compliance. Records reviewed to include identified need and what type of assistance staff are to provide to include coordinated services, basic needs identified, and signature of legal representative. Community will continue to complete Preliminary ISP and Comprehensive ISP in conjunction with resident, family, and/or caregivers while using the History and Physical, physician orders, UAI, and other support to ensure the individualized basic needs of the resident are adequately identified to include type of assistance needed to protect the resident?s health, safety, type of assistance required by coordinated services if applicable, and required signatures. Executive Director will review the Preliminary ISP on the date of admission. Executive Director, Resident Care Director, and/or designee reviewed other ISPs to ensure compliance. Executive Director will complete random monthly audit of a minimum of 5 Comprehensive ISPs to ensure ongoing compliance."
Standard #:	22VAC40-73-580-F
Description:	Based on the review of facility records with the Administrator on 09/30/2019 the facility failed to implement interventions for a resident as soon as a nutritional problem is suspected. Resident #7 The facility's Summary of Nutrition Review dated 06/24/2019 that was submitted for the inspector's review noted "14.2 lb weight loss in two months, a 7% loss". Add No Added Salt diet order to POS and remove Regular from A! Advantage. Maintain current weight." The facility did not submit for the inspector's review documented evidence that interventions had been implemented to address the resident's weight loss.
Plan of Correction:	Resident #7 is no longer a resident at the community. All other current dietician summaries with recommendations were reviewed on Oct 8, 2019 by the Resident Care Director/Assistant FACILITY RESPONSE- "Resident Care Director and Executive Director. Interventions have been implemented as appropriate and added to the Resident ISP?s. Resident Care Director or designee and Executive Director or designee will review Dietician summaries when received to ensure implementation of interventions as soon as a nutritional problem is suspected."