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: June 24, 2020 , June 30, 2020 , July 7, 2020 , July 16, 2020 , July 27, 2020 and Aug. 3, 2020

Complaint Related: No

Areas Reviewed:

Part II- Administration and Administrative Services Part IV- Staffing and Supervision Part VI- Resident Care and Related Services Part X- Additional Requirements for facilities that care for adults with serious cognitive impairments

Comments:

This inspection was conducted by licensing staff using an alternative remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. The evidence gathered during the investigation supports the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-1180-B
Description:	Based on record review and staff 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 shall be inaccessible to the resident except under staff supervision. Evidence: 1. On 6-17-20 an incident was received noting "accidental ingestion" by resident #1. Further review of the report noted, resident "entered behind a staff member into the kitchen area of Sweet Memories. ..picked up a bottle of lavender essential oil.." 2. On 6-30-20 during interview, staff #4 stated, coming out of the medication room and "observed resident with bottle to his lips and took a sip of lavender scented oil". According to staff's statement during interview and documentation in the resident's Progress Notes on 6-16-20 at 12:20 pm staff " noticed resident had a purple glass bottle in his hand"...approached resident and asked to see the bottle...attempted to retrieve bottle from resident, resident refused and writer bargained with resident and was given chocolate ensure.." 3. Progress Notes dated 6-16-20 at 2:21 pm, noted staff #4 documented, staff #2 administered milk to resident #1, per Poison Control.
Plan of Correction:	All staff reeducated on resident safety, oversight, and removal of any harmful material or objects during meals, and or activities. Staff In-serviced on proper Handling and Removing of any harmful material and or objects for resident safety. RCD, ARCD, and or designee will monitor for continued regulatory compliance. Staff In-serviced on proper Handling and Removing of any harmful material and or objects for resident safety. RCD, ARCD, and or designee will monitor for continued regulatory compliance. ED, RCD, ARCD, and or designee to review clinical policy and follow per company standards. Person Responsible: ED, RCD, ARCD, and or designee Completed on 6/17/20
Standard #:	22VAC40-73-40-A
Description:	Based on document review and staff interview, the facility failed to ensure compliance with the facility's own policies and procedures. Evidence: 1. On 6-17-20, an incident was received from the facility via e-mail stating an "accidental ingestion". During the inspection a copy of the facility's resident emergency policy was requested and received on 7-16-20. A review of the policy submitted was completed. According to facility policy CL11- Medical Emergency, "The Community summons emergency medical services (call 911)* when the resident exhibits signs and symptoms of distress and/or emergency condition. Examples include, but are not limited to: .....m) Poisoning". 2. During the course of staff interviews no staff stating calling emergency services. There were no documentation presented, indicating emergency medical services was summon. The nurses note in resident #1's record of the account on 6-16-20 did not document emergency medical services (911) being contacted. 3. Staff #1 acknowledged, the facility did not call 911 as noted in the policy, which noted poisoning listed as one of the examples for summoning medical services.
Plan of Correction:	ED, RCD, ARCD, and or designee to know clinical policy and follow per company standards. The policy was reviewed with all staff. Particular emphasis was on alerting EMS when there is a suspected or known poison ingestion. Person responsible: ED, RCD, ARCD and or designee Due date: 6/30/20
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan included all assessed needs for a resident. Evidence: 1. During the remote inspection, a review of resident #1's uniformed assessment instrument (uai) dated 6-18-20 indicated resident independent (no help needed) with bladder. However, the individualized service plan (ISP) dated 6-23-20 indicated urinary incontinence, less than weekly; human help/supervision by direct care staff and registered medication aide. 2. Further review of the uai noted resident #1, assessed as disoriented in some spheres all the time (time, place, situation). However, this assessed need is not on the ISP. 3. During interview on 7-27-20, staff #3 acknowledged resident #1's assessed needs on the uai and ISP were not in agreement.
Plan of Correction:	UAI updated to reflect current assistance needed with bladder. Any change in condition will be reviewed and the UAI will be updated to reflect changes and to remain in regulatory compliance. ISP has been updated accordingly to reflect current identified needs on resident #1 pending family review and signature. Any change in condition will be reviewed and the UAI will be updated to reflect changes and to remain in regulatory compliance Person Responsible: RCD/ARCD Person Responsible: RCD, ARCD, and or Designee Completed 8/19/20