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: Nov. 9, 2020 , Nov. 12, 2020 and Dec. 22, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 complaint inspection was initiated on 11-10-20 and concluded on 12-18-20. A complaint was received by the department regarding an allegation in the area of resident accommodations and related provisions. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.

Violations:

Standard #:	22VAC40-73-100-C-1
Complaint related:	No
Description:	Based on interview, the facility failed to ensure the implementation of infection prevention measures by staff to include the sanitation of equipment. Evidence: 1. Interview with staff members, staff reported resident #1?s wheelchair was not being cleaned and there was no scheduled for cleaning of the wheelchair. Interview with staff members, staff stated an abundance of maggots were reported to be in the pocket of resident #1?s wheelchair. Staff stated the maggots were cleaned from the pocket of resident #1?s wheelchair late October 2020. 2. Interview with resident #1?s legal representative confirmed observing maggots in the pocket of wheelchair while visiting with resident. Representative stated one of the staff person cleaned the wheelchair. 3. Interview with staff #1, staff confirmed maggots were observed in the pocket of resident #1?s wheelchair. Staff also stated the facility did not have a cleaning schedule for resident?s wheelchair prior to the incident in October 2020.
Plan of Correction:	What Has Been Done to Correct? Implementation of wheelchair cleaning schedule with sign off sheet. Staff education. How Will Recurrence Be Prevented? Continuing staff education of monthly sign off sheet with monthly audit of completion performed by RCD and ARCD Person Responsible: RCD, ARCD or designee Due Date: 3/24/21
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure the resident?s individualized service plan (ISP) included all required information. Evidence: 1.Resident #1?s individualized service plan (ISP) dated 8-20-20 did not include all required information for assessed needs documented. The following needs documented on the ISP: emergency evacuation, bathing, dressing, escorts, fall potential, mobility/ambulation, transferring, psychosocial and toileting did not include persons who will provide services and when or where services will be provided. 2.Resident #1?s ISP indicated resident?s need for escort noted resident ?requires hands on assistance and has an assistive device for mobility/ambulation?. The assistive device needed is not documented. 3.Resident #1?s medication administration record (MAR) for October 2020 and November 2020 documented resident is administered Sertraline for depression. The resident?s November 10, 2020 Physician Order Review documented Sertraline HCL prescribed for depression, order date 6-12-2020. Resident?s ISP noted psychosocial need dated 8-20-20 documented, ?resident does not have current or history of depression or mood disorder?. 4. Resident #1?s uniformed assessment instrument (UAI) dated 8-20-20 documented resident is independent for incontinence. Resident?s October 2020, November 2020 MAR and November 10, 2020 Physician Order Review documented Baza cream for ?incontinence?. According to interview with multiple staff members, resident?s incontinent products are located in resident?s room. Resident?s billing statement for September 2020 and October 2020 documented ?supply fee?. According to interview with the business office staff, the ?supply fee? is for incontinent products used by the resident. 5. Resident #1?s Physician Order Review dated November10, 2020 documented resident allergic to Oxycodone, this information not documented on resident?s ISP dated 8-20-20.
Plan of Correction:	What Has Been Done to Correct? Resident's ISP has been updated to reflect needs, persons and assistive devices. Resident's UAI updated to reflect diagnosis of depression, allergies and incontinence. How Will Recurrence Be Prevented? ED, RCD or designee to perform random monthly audits of UAI's and ISP's to ensure ongoing compliance. RCD and ARCD will update ISP semi-annually or upon change of resident condition. Person Responsible: ED, RCD or designee Due Date: 3/24/21
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure the facility?s medication administration record (MAR) included all required information. Evidence: 1. Resident #1?s October 2020 medication administration record (MAR) did not include initials /was blank for the following medications: (a) Acetaminophen 500 mg tablet scheduled for 8:00 a.m. blank 21 times; 1:00 p.m. 20 times and 8:00 p.m. 1 time. (b) Acidophilus tablet scheduled for 8:00 a.m. blank 21 times. (c) Amiodarone HCL 200 mg tablet scheduled for 8:00 a.m. blank 21 times. (d) Baza cream scheduled for 8:00 a.m. blank 21 times; 1:00 p.m. blank 19 times and 8:00 p.m. 1 time. (e) Diltiazem 240 mg tablet scheduled for 8:00 a.m. blank 21 times. (f) Ensure scheduled for 8:00 a.m. blank 21 times. (g) Levothyroxine 200 mcg tablet scheduled for 8:00 a.m. blank 21 times. (h) Levothyroxine 25mcg tablet scheduled for 8:00 a.m. blank 21 times. (i) Calcium Carbonate-Vitamin D 500-200 mg-unit tablet scheduled for 8:00 a.m. blank 21 times. (j) Sertraline HCL 25 mg tablet scheduled for 8:00 a.m. blank 21 times and (k) Vitamin D3 50000 unit capsule scheduled for 8:00 a.m. blank 21 times. 2. November 1 through 9, 2020 MAR did not include initials/ was blank for the following medications: (a) Acetaminophen 500 mg tablet scheduled for 8:00 a.m. blank 6 times and 1:00 p.m. 6 times. (b) Acidophilus tablet scheduled for 8:00 a.m. blank 6 times. (c) Amiodarone HCL 200 mg tablet scheduled for 8:00 a.m. blank 6 times. (d) Baza cream scheduled for 8:00 a.m. blank 6 times and 1:00 p.m. blank 6 times. (e) Diltiazem 240 mg tablet scheduled for 8:00 a.m. blank 6 times. (f) Ensure scheduled for 8:00 a.m. blank 6 times. (g) Levothyroxine 200 mcg tablet scheduled for 8:00 a.m. blank 6 times. (h) Levothyroxine 25 mcg tablet scheduled for 8:00 a.m. blank 6 times. (i) Calcium Carbonate-Vitamin D 500-200 mg unit tablet scheduled for 8:00 a.m. blank 6 times. (j) Sertraline HCL 25 mg tablet scheduled for 8:00 a.m. blank 6 times and (k) Vitamin D3 50000 unit capsule scheduled for 8:00 a.m. blank 6 times. 3. On 12-18-20 during exit, Staff #1 acknowledged the MARs did not include staff initials (MARs were blank).
Plan of Correction:	What Has Been Done to Correct? EMAR system error was identified. Error was preventing initials of a particular med tech from appearing on EMAR when medications were given. How Will Recurrence Be Prevented? Error was corrected and initials now appear on EMAR Person Responsible: ED, RCD Due Date: 3/24/21