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: May 18, 2020 , May 19, 2020 and May 21, 2020

Complaint Related: No

Areas Reviewed:

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 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 5-19-20; 5-20-20; 5-21-20 and concluded on 5-22-20. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 48. The inspector e-mailed the administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, staff schedule, fire inspection, health department inspection, fire and emergency drills, oversight dietitian/nutritionist and new hire since last renewal inspection ( date of hire, sworn statement/affirmation and criminal history record report. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1140-A
Description:	Based on document review and staff interview, the facility failed to ensure within three months of the start of employment, the administrator attended at least 12 hours of training in cognitive impairment. Evidence: 1. During the remote inspection, a review of staff #1's training information indicated staff completed eight (8) hours of cognitive impairment training on 11-19-19. According to documents submitted on 5-21-20 clarifying staff #1's date of employment at the facility, staff's date of hire was noted as 11-11-29. 2. On 5-22-20 during the exit interview, staff #1, acknowledged not having the required number of cognitive training hours within 3 months of the starting date of employment.
Plan of Correction:	What Has Been Done to Correct? 8 additional hours of cognitive impairment training have been completed to total the 12 hours state regulation requirement. How Will Recurrence Be Prevented? Administrator cognitive impairment training hours will be added to the business office manager?s tracking tool. Monthly audits will be conducted to ensure compliance. Person Responsible: Executive Director, Business Office Manager Due Date: 6/17/20
Standard #:	22VAC40-73-290-A
Description:	Based on document review and staff interview, the facility failed to ensure the written work schedule included all of the required information. Evidence: 1. On 5-21-20 during the remote inspection and second request for the staff schedule, the written schedule submitted for the nursing department's safe, secure unit (ssu) Sweet Memories did not include required information. The May 3, 2020 thru May 20, 2020 written schedule for the Sweet Memories (ssu) did not include the job classification for the individuals listed under the heading "staff person". 2. Further review of the May 2020 Sweet Memories staff schedule noted "first name" of individual staff persons and staff scheduled as the nurse/med aid for the day shifts, evening shift and ?noc? shift. 3. Staff #1 acknowledged the May 2020, Sweet Memory schedule submitted during the remote renewal inspection did not include all required information.
Plan of Correction:	What Has Been Done to Correct? Re-education of staff on proper completion of written working schedule. Which will include first and last name of all staff members along with a legend identifying person in charge each shift. How Will Recurrence Be Prevented? Review of working scheduled will be done daily by the Resident Care Director or Assistant Resident Care Director to ensure accuracy and updates. Person Responsible: Resident Care Director, Assistant Resident Care Director Due Date: 06/17/2020 and ongoing
Standard #:	22VAC40-73-310-H
Description:	Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without appropriate treatment plan for two of three residents. Evidence: 1. On 5-19-20 during the remote renewal inspection, a request for physician?s orders for treatment plan for psychotropic medication on the residents? April 2020 medication administration record (mar) was made. A review of documents received on 5-20-20 did not include treatment plan for psychotropic medications for resident #2 and #3. 2. On 5-21-20, approximately 10:10 am, during a telephone conversation with staff #1, a request for documents not received on 5-21-20 was made. Included in the request was for treatment plans for psychotropic medications for residents #2 and #3. 3. On 5-21-20, approximately 3:10 pm, the treatment plan for resident #2?s Haldol, dated 5-21-20 was received and resident #3?s treatment plan for Zoloft, dated 5-21-20 was also received. The time and date noted on the treatment plans for resident #2 and resident #3 noted a date of 5-21-20, with a time following the inspector?s telephone conversation with staff #1, requesting the treatment plans. 4. During the exit interview on 5-22-20, with staff #1, the treatment plans with a date of 5-21-20 and the time noted on the fax was shared as to when the facility obtained the treatment plans. 5. Staff #1 acknowledged the treatment plans were not obtained prior to the inspector?s request on 5-21-20 and inspection date on 5-19-20.
Plan of Correction:	What Has Been Done to Correct? Psychotropic treatment plans have been implemented for Resident #2 and #3. How Will Recurrence Be Prevented? Medications will be reviewed thoroughly by the Resident Care Director or Assistant Resident Care Director upon admission and every 6 months to include any changes. Pharmacy Consultant will also provide oversight and recommendations that will be communicated with physician. Person Responsible: Resident Care Director, Assistant Resident Care Director Due Date: 07/10/2020 and ongoing
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for two of three residents. Evidence: 1. During the remote inspection, a review of resident #1's uniformed assessment instrument (uai) dated 4-23-20 noted bathing human help/physical assistance (hh/pa), however, the individualized service plan (ISP) dated 4-23-20 noted mechanical/supervision/physical assistance. The ISP did not indicate what mechanical device was needed. Dressing on the uai noted hh/pa, however, the ISP noted mechanical/supervision/physical assistance, but did not indicate what mechanical device was needed. The signed physician's order date 5-19-20 noted resident #1's diet as mechanical soft, regular, no added salt (NAS), however, the ISP circled a low Na/mechanical soft diet. The uai noted walking assessed as mechanical help/human help/physical assistance (mh/hh/pa; wheeling assessed as mechanical help; stairclimbing assessed as mh/hh/pa; mobility assessed as mh/hh/supervision. However the ISP grouped together walking, wheeling, stairclimbing and mobility with physical assistance services to be provided.The uai noted disorientation, some spheres, some time, however, the ISP noted (circled ) no for disoriented need. 2. Resident #2's uai dated 4-13-20 noted bowel and bladder assessed as incontinent weekly or more, however, the ISP dated 5-20-20 did not address the assessed need for bowel and bladder. Walking and stairclimbing assessed on the uai as not performed, however, the ISP did not address the assessed needs. 3. Resident #3's uai dated 1-23-20 stairclimbing assessed as not performed, however the ISP dated 5-20-20 did not address the assessed need. 4. On 5-22-20 during the exit interview, staff #1 acknowledged the residents' ISP did not include all assessed needs.
Plan of Correction:	What Has Been Done to Correct? Resident #1,2,3 ISP updated to reflect residents? current needs . How Will Recurrence Be Prevented? Resident Care Director and Assistant Resident Care Director will ensure that each ISP is reviewed and updated annually or if there is a change in residents? condition. ISP?s will continue to be reviewed to ensure compliance. Records will be reviewed to include identified needs and what type of assistance staff are to provide; coordinated services, basic needs, and mechanical assistance/help. ISP?s will be reviewed by Executive Director after each care plan meeting. Person Responsible: Executive Director, Assistant Executive Director, Resident Care Director, Assistant Resident Care Director, and/or Designee Due Date: 07/10/2020 and ongoing