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: April 12, 2021 , April 13, 2021 , April 28, 2021 and April 30, 2021

Complaint Related: No

Areas Reviewed:

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 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 monitoring inspection was initiated on 4-12-21 and concluded on date 4-29-21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was thirty-nine. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three staff records, three resident records, staff schedule, health and fire inspection, fire drills and health care oversight documents. 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-E
Description:	Based on record review and staff interview, the facility failed to ensure within the first month of employment, staff, other than the administrator and direct care staff, who will have contact with the residents in the special care unit shall complete two hours of training on the nature and needs of residents with cognitive impairments due to dementia. Evidence: 1. Staff #7?s training record submitted documented staff?s date of hire and first date of work was 8-28-20. Staff?s training record documented staff?s cognitive training began on 10-6-20. 2. On 4-28-21, staff #1 acknowledged staff #1 did not complete two hours of cognitive training within the first month of employment.
Plan of Correction:	What Has Been Done to Correct? Staff received training on 10/6/20 How Will Recurrence Be Prevented? All required training due within first 90 days will be completed during initial orientation period of 2 weeks. Person Responsible: BOM, ED or designee Due Date: 5/16/21 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 without required documentation. Evidence: 1. Resident #3?s March 2021 documented resident is administered Sertraline HCL- 50 mg daily. The resident?s physician?s order dated 3-16-21 also documented Sertraline HCL 50 mg daily. A copy of the resident?s treatment plan for this psychotropic medication was not submitted. 2. On 4-28-21 during the initial exit with staff # 1 and #2, a request was made for documentation of the psychotropic treatment plan for resident #1?s Sertraline. 3. On 4-29-21 during the final exit with staff #1, staff acknowledged the facility did not have the treatment plan for resident #3?s psychotropic medication, Sertraline.
Plan of Correction:	What Has Been Done to Correct: Resident #3?s psychotropic treatment plans were implemented. How Will Recurrence Be Prevented? Medications will be reviewed upon admission, every six months, when changes occur and added to psychotropic plan if indicated. Person Responsible: RCD, ARCD or designee Due Date: 5/15/21 and ongoing
Standard #:	22VAC40-73-320-A
Description:	Based on record review and staff interview, the facility failed to ensure the physical examination included all required information for one of three resident records. Evidence: 1. Resident #1?s admitting physical examination dated 10-9-20 did not include the resident?s height and blood pressure information. 2. Staff #1 and #2 acknowledged on 4-28-21, resident #1?s physical examination did not include height and blood pressure.
Plan of Correction:	What Has Been Done to Correct? RCD contacted discharging facility to correct original H&P for Resident #1 to include height and blood pressure information from their records. How Will Recurrence Be Prevented? Resident History and Physicals will be reviewed for completion prior to admissions, if additional information is required the physician will be contacted for completion. Person Responsible: RCD, ARCD or designee Due Date: 5/16/21 and ongoing
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 one of three residents. Evidence: 1. Resident #1?s physical examination dated 10-9-20 documented resident allergic to Genteal and Adhesive tape. This information was not documented on the resident?s individualized service plan (ISP) dated 4-14-21. 2. On 4-28-21, staff #1 and #2 acknowledged resident?s allergy to Genteal and adhesive tape was not documented on resident?s ISP.
Plan of Correction:	What Has Been Done to Correct? Resident #1?s Individualized service plan was reviewed for accuracy to ensure all information included. How Will Recurrence Be Prevented? Resident Individualized service plans will be reviewed semi-annually and when change of condition occurs. Person Responsible: RCD, ARCD or designee Due Date: 5/16/21 and ongoing
Standard #:	22VAC40-73-650-B
Description:	Based on record review and staff interview, the facility failed to ensure the physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall include the name of the resident, date of the order, the name of the drug, route, dosage, strength, how often the medications is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. Resident #1?s medication administration record (MAR) for March 2021 did not include the diagnosis, condition or specific indications for Potassium Chloride ER- 20 MEQ and Refresh Plus Ophthalmic solution. The physician order signed and dated 3-16-21 did not include the diagnosis for the aforementioned medications prescribed. 2. On 4-28-21, a request was made for a signed and dated physician or other prescriber?s document that included the diagnosis for resident #1?s Potassium Chloride ER 20 MEQ and Refresh Plus Ophthalmic solution. 3. On 4-29-21 during the final exit with staff #1, staff acknowledged the facility did not have documentation of the diagnosis for resident #1?s Potassium Chloride 20 MEQ and Refresh Plus Ophthalmic solution.
Plan of Correction:	What Has Been Done to Correct? Resident #1?s records reviewed for completion for the name of drug, route, dosage, strength, frequency given and identified the diagnosis for each administered medication. How Will Recurrence Be Prevented? Resident record will be reviewed prior to admission for completion of the 5 rights and diagnosis of each medication and every six months and when new orders received. Person Responsible: RCD, ARCD or designee Due Date: 5/16/21
Standard #:	22VAC40-90-40-C
Description:	Based on document review and staff interview, the facility failed to ensure it did not employ anyone ineligible for employment if the criminal history record report contain conviction of a barrier crime. Evidence: 1. A review of staff #8?s sworn disclosure dated 3-29-21, documented a potential barrier crime. 2. Staff #8?s criminal history record report dated 3-30-21 included a barrier crime with the date of 11-17-2017. The staff?s date of hire was documented as 4-7-21. 3. On 4-28-21 acknowledged staff was employed at the facility.
Plan of Correction:	What Has Been Done to Correct? Staff records reviewed for all staff to ensure eligibility for employment based on criminal history record. How will Recurrence Be Prevented? Applicant criminal record will be reviewed by ED or designee prior to hire. Person Responsible: BOM, ED or designee Due Date: 5/16/21 and ongoing