VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at King's Grant House
440 North Lynnhaven Road
Va. beach, VA 23452
(757) 431-8825

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: June 30, 2021 , July 1, 2021 and July 2, 2021

Complaint Related: No

Comments:

A renewal inspection was initiated on 06-30-2021 and concluded on 07-02-2021.The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 48. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 3 resident records, 3 staff records, activities calendar, staff schedules, fire drills, fire and health inspection reports, dietary and healthcare oversights, and menus submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 07-02-2021. An exit interview was conducted with the Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. 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 #:	22VAC40-73-1090-A
Description:	Based on record review and interview, the facility failed to ensure prior to admission to a safe, secure environment, the resident was assessed in writing by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Resident #1 was admitted to the facility on 03-04-2020. The resident?s Individualized Service Plan dated 02-27-2021 documented the resident will reside in the Sweet Memories secure unit [special care unit] with a date identified as of 07-02-2020. 2. Resident #1?s ?Assessment of Serious Cognitive Impairment? form was signed and dated by the Nurse Practitioner (NP) on 07-08-2020. The NP answered ?no? to the question, "Does the individual named above have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia.? The form also documented ?Pt was moved to memory unit on 07-02-2020 due to symptom exacerbation?? 3. Staff #1 acknowledged resident #1 was placed on the safe, secure environment prior to the resident being assessed by a physician in writing, and that the resident was not assessed as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia.
Plan of Correction:	What Has Been Done to Correct? Community NP was notified of error on ?Assessment of Cognitive Impairment Form?. Form will be updated during NP?s next visit to King?s Grant Community. How Will Recurrence Be Prevented? Community will conduct a chart audit within the first week of a room change to make sure all documentation pertaining to the room change is updated by all parties. Person Responsible: RCD/ARCD Due Date: 9/27/2021
Standard #:	22VAC40-73-450-F
Description:	Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) was reviewed and updated as needed as the condition of the resident changes. Evidence: 1. Resident #1?s current Uniform Assessment Instrument (UAI) dated 03-18-2021 documented the need for supervision with mobility, and mechanical assistance with stairclimbing; however, the current ISP dated 02-27-2021 was not updated to reflect a description of services explaining how staff would supervise the resident with mobility; nor did the ISP document the type of mechanical device needed for stairclimbing. 2. During a tour of the facility with staff #1 on 07-02-2021, a concentrator and portable oxygen tanks were observed by resident #2?s bed. Resident #2?s oral order dated 03-23-2021 documented, ?02 @ 2L/NC PRN [as needed] for dyspnea; however, the current ISP dated 03-13-2021 was not updated to reflect the resident?s need for oxygen. Staff #2 also confirmed the resident is on PRN oxygen. 3. Resident #3?s current UAI dated 05-26-2021 documented the need for supervision with walking and mobility; supervision and mechanical assistance with stairclimbing; and physical and mechanical assistance with stairclimbing; however, the current ISP dated 05-26-2021 was not updated to reflect a description of services explaining how staff would supervise the resident with mobility, transferring, and walking; nor did the ISP document the type of mechanical device needed for stairclimbing and mobility. 4. Staff #1 acknowledged resident #1, resident #2, and resident #3?s ISPs were not updated to reflect the residents? aforementioned needs.
Plan of Correction:	What Has Been Done to Correct? ISP for Resident #1 has been updated to reflect mechanical assistance needed stair climbing and explained how staff would assist. ISP for Resident #2 has been updated to reflect the resident?s need for PRN oxygen use. ISP for Resident #3 has been updated to reflect mechanical assistance needed stair climbing ISP also updated to reflect a description of service of how staff would assist resident with mobility, transferring, and walking. How Will Recurrence Be Prevented? Community has implemented bi-weekly ?At-risk/ISP? meeting to conduct audits on residents ISP/UAI documentation and physician orders. Person Responsible: RCD/ARCD/ED Due Date: 8/25/21 initial meeting will be conducted. On-going meetings will be conducted bi-weekly going forward.