VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at South Boston
435 Hamilton Boulevard
South boston, VA 24592
(434) 575-5400

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: June 23, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

A non-mandated complaint inspection was initiated on 06/23/2021 and concluded on 08/23/2021. A complaint was received by the department regarding allegations in the areas of resident care and related services. 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 supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-1040-A
Complaint related:	Yes
Description:	Based on a review of resident records and staff interviews, the facility failed to ensure that a system of security monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms were available/operational on all doors leading to the outside. EVIDENCE: 1. The facility serves a mixed population as indicated by documentation in the records for resident?s 1, 2 and 3. 2. The record for resident 1 has documentation in progress notes dated 05/11/2021 that resident 1 was found by staff outside at 1:30am ringing the doorbell. Interviews with staff person 1 expressed that the door alarm system was not alarming at the time resident 1 was outside of the building and that the doorbell being pushed by resident 1 was the only sound that staff person 1 heard to alert her that someone was outside. Interviews with other staff expressed that the front door alarm is often cut off during the day and is not always turned back on during the evening or night shifts. 3. The record for resident 2 has documentation in progress notes that another resident alerted staff that resident 2 was outside knocking on the facility windows on 01/29/2021 and found by staff in the facility parking lot attempting to get into someone's car on 02/13/2021. On 7/12/2021 at 1:41pm, progress notes in resident 2's record has documentation that resident 2 was found outside on the main highway by one of her family members. The family member called the facility to notify staff and staff were able to retrieve resident 2 and return her to the facility. Interviews with staff expressed that on 07/12/2021, an individual was in the facility applying for employment and had let resident 2 out the door upon her request. 4. Documentation in progress notes for resident 3 indicates that on 04/02/2021 resident 3 escaped out of the front door without his walker and fell in the parking lot and rolled down the hill. He was observed by a kitchen staff member who was going to her car. Staff assisted resident 3 back into the building and into his room and that resident 3 was continuing to attempt to get out of all doors of the building.
Plan of Correction:	RCD has reassessed all AL residents to determine appropriateness for AL. Residents 2 and 3 have been relocated to MC. Resident 1 has been issues a d/c notice. Any residents in questions will be reviewed with ED and will be evaluated by CSL Medical Director to determine qualification for Secured Unit and or Discharge. Residents determined appropriate for the Secured Unit will be discussed with ED and families to arrange for transfer to secured unit. Interventions will be implemented as indicated to ensure the safety of any Resident pending disposition to a Secured Unit and or Discharge. Person Responsible: RCD
Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on a review of resident records the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. EVIDENCE: 1. The record for resident 1 has documentation in progress notes dated 05/11/2021 at 2:42am ?1:30pm I was the assisting a resident when I came out of the room I heard the front doorbell ring. I looked outside and observed resident standing at the door trying to get back in the building. I was able to redirect her back to her room and she went back to bed?. Interviews with staff explained that this incident occurred at 1:30am on 05/11/2021. As of the date of this inspection, the facility had not reported this incident to the regional licensing office. 2. The record for resident 2 has documentation in progress notes dated 1/30/2021 that ?resident was resting in the lobby last night at 6:50pm. Around 7:05pm a resident came up from activities and said resident 2 was knocking on the window. RCA went to get her from outside and she said she was just walking. RCD and ED were notified and POA was called?. Progress notes for resident 2 dated 2/13/2021 at 8:29pm has documentation that ?resident was observed outside in the parking lot attempting to get into someone's car. She had taken the keys. Stated she snuck out and was trying to sneak back in, but got locked out. Memory Care RCA assisted her back in the building. c/o lower back pain but refused to take prn pain medicine?. As of the date of this inspection, the facility had not reported these incidents to the regional licensing office. 3. The record for resident 3 has documentation in progress notes dated 4/2/2021 at 7:08pm that ?resident 3 escaped out of the front door without his walker and fell outside in the parking lot rolling down the hill. Was observed by a kitchen staff when going to her car. No apparent injuries RCA?s assisted him back into the building into his room. Continues to try and get out of all doors in the building?. As of the date of this inspection, the facility had not reported this incident to the regional licensing office.
Plan of Correction:	All incidents requiring notification post 8/16/21 have been submitted. Facility will review and report any incident that jeopardize life, safety, or wellbeing of a resident with in 24 hours per the DSS regulations Person Responsible: ED and RCD
Standard #:	22VAC40-73-280-A
Complaint related:	No
Description:	Based on a review of resident records, employee schedules and interviews with staff, the facility failed to ensure that staffing was sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident. EVIDENCE: 1. The record for resident 1 has documentation in progress notes dated 05/11/2021 at 2:42am ?1:30pm I was the assisting a resident when I came out of the room I heard the front doorbell ring. I looked outside and observed resident standing at the door trying to get back in the building. I was able to redirect her back to her room and she went back to bed?. The record for resident 1 has documentation in progress notes dated 05/11/2021 at 2:50am ?1:30am RCA was in memory care relieving staff, so one of the staff could take a break. I was the only staff on the floor assisting residents at the time resident was observed outside of the front doors?. Interviews with staff explained that this incident occurred at 1:30am on 05/11/2021. 2. The facility AL unit was noted to have a census of 33 residents on 05/11/2021. At least three of these residents, including resident 1, have documentation in their records of having a diagnosis of dementia, periods of disorientation/confusion and wandering behaviors, making the AL unit a mixed population. Residents 2 and 3 have documentation in their records of previous elopements from the facility building prior to 05/11/2021. 3. The facility employee schedule for 5/11/2021 has 2 direct care staff scheduled to work on the AL unit on the NOC (night) shift. Interviews with staff explained that 2 direct care staff are regularly scheduled to work the AL unit on the NOC shift but that 1 direct care staff from the AL unit is required to report to the locked memory care unit to relieve the memory care staff for their breaks. Interviews with staff indicated that the direct care staff scheduled for the AL unit are usually gone from the AL unit for an hour to an hour and a half while the memory care staff take their breaks. This leaves only 1 direct care staff person working the AL unit during this time to provide care and oversight for all residents residing on the AL unit including residents who have a diagnosis of dementia.
Plan of Correction:	Staffing in AL shall meet the requirements for a mixed population per DSS guidelines Community will adjust staffing needs temporarily while there is a mixed population until mixed population is resolved. Staffing schedules will be reviewed daily by scheduler and ARCD to ensure appropriate coverage. RCD to review weekly and ED will review schedules monthly to ensure compliance. Person Responsible: ARCD, RCD, and ED
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on a review of resident records, the facility failed to ensure that individualized service plans (ISPs) were updated as needed for a significant change of a resident?s condition. EVIDENCE: 1. The record for resident 1 has documentation in progress notes of the resident being confused ,up and fully dressed and needed to be redirected back to her room on 04/30/2021 at 2:26am and 05/01/2021 at 4:35am. On 05/11/2021 at 2:42am documentation in resident 1?s progress notes indicates that resident 1 was found outside of the front doors of the facility. The comprehensive ISP dated 06/22/2021 in the record for resident 1 has not been updated to address the identified need for wandering. 2. The record for resident 2 has documentation in progress notes between 09/21/2020 through 07/12/2021 of 4 episodes of the resident being confused. Progress notes also has documentation on 01/30/2021, 02/13/2021 and 07/12/2021 that resident 2 was found outside of the facility building. The record for resident 2 has documentation on 07/12/2021 that resident 2 was assessed as having a serious cognitive impairment and is unable to recognize danger or protect their own safety or welfare and was admitted to the facility safe, secure unit. The comprehensive ISP dated 08/29/2020 in the record for resident 2 was not updated between 09/21/2020 through 07/12/2021 to address the identified needs for confusion and wandering. 3. The record for resident 3 has documentation in progress notes on 03/19/2021 and 03/28/2021 that resident 3 was attempting to get out of the front door. Documentation in progress notes for resident 3 indicates that on 04/02/2021 at 7:08pm, resident 3 escaped out of the front door without his walker and fell in the parking lot and rolled down the hill. Documentation in progress notes dated 04/17/2021 and 07/03/2021 indicates that resident 3 left the 200 hallway and set off the alarms. The comprehensive ISP dated 03/23/2021 in the record for resident 3 has documentation under psychosocial that the resident goes to the door and is looking for his car, we keep reminding him that his car is not here and that resident does not exit seek. The ISP was not updated to reflect resident 3?s identified need for wandering.
Plan of Correction:	Currently updating all ISP to reflected potential significant change. All ISPs shall be reviewed and updated in accordance with CSL Policy and DSS regulations. RCD will run Yardi report weekly to identify any upcoming ISP's due and ensure timely completion of all assessments due. Reports will be discussed with ED weekly until all are current and then monthly thereafter. RCD/ED will review completed assessments for accuracy and conduct a care plan meeting with resident and or family. Any Resident identified with a Change in Condition will be assessed immediately and Actions/Interventions will be implemented accordingly to ensure the safety and wellbeing of the Resident. Additionally, the UAI and ISP will be updated respectively to reflect such Changes/Actions/Interventions. ED will review Yardi dashboard weekly to ensure compliance for UAI/ISP Persons Responsible: RCD, ED
Standard #:	22VAC40-73-460-D
Complaint related:	Yes
Description:	Based on a review of resident records, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized need of wandering from the premises. EVIDENCE: 1. The physical exam dated 10/02/2019 in the record for resident 1 has documentation that the resident has a diagnosis of Traumatic Subracial Hemorrhage, Delusional Disorder, and was prescribed Donepezil HCL 10mg for Dementia R/T Alzheimer's. 2. The uniform assessment instrument (UAI) dated 06/22/2021 in the record for resident 1 has documentation that the resident requires supervision with mobility and disorientation to some spheres some of the time with time, place and situation being the spheres affected. 3. The individualized service plan (ISP) dated 06/22/2021 in the record for resident 1 has documentation that the resident has short term memory loss and a history of occasional disorientation to person, place, time or situation even in familiar surroundings and requires supervision and oversight for safety. 4. The record for resident 1 has documentation in progress notes of the resident being confused ,up and fully dressed and needed to be redirected back to her room on 04/30/2021 at 2:26am and 05/01/2021 at 4:35am. Progress notes dated 05/11/2021 at 2:42am ?1:30pm I was the assisting a resident when I came out of the room I heard the front doorbell ring. I looked outside and observed resident standing at the door trying to get back in the building. I was able to redirect her back to her room and she went back to bed?. Interviews with staff explained that this incident occurred at 1:30am on 05/11/2021. 5. The physical exam dated 09/09/2019 has documentation that resident 2 has a diagnosis of dementia. Physician orders review dated 07/22/2021 has that resident 2 was prescribed Memantine HCL 10mg for dementia on 03/15/2021. 6. A UAI dated 02/20/2021 in the record for resident 2 has documentation that the resident is disoriented to some spheres all of the time. 7. A preliminary ISP has documentation dated 09/15/2019 that resident 2 has disorientation to place and time and for staff to orient and redirect as necessary. An ISP dated on 10/16/2019 has documentation under safety that resident 2 cannot leave the premises unassisted. The ISP dated 08/29/2020 in the record for resident 2 was not updated to address the residents needs for confusion and wandering. 8. The record for resident 2 has documentation in progress notes between 09/21/2020 and 07/12/2021 of the resident being combative (11 episodes) and confused (4 episodes). Progress notes dated 1/30/2021 indicate, ?Resident was resting in the lobby last night at 6:50pm. Around 7:05pm a resident came up from activities and said resident 2 was knocking on the window. RCA went to get her from outside and she said she was just walking. RCD and ED were notified and POA was called?. The outside temperature was a high of 39'F at the time of this incident. Progress notes for resident 2 dated 2/13/2021 at 8:29pm has documentation that ?resident was observed outside in the parking lot attempting to get into someone's car. She had taken the keys. Stated she snuck out and was trying to sneak back in, but got locked out. Memory Care RCA assisted her back in the building. c/o lower back pain but refused to take prn pain medicine?. The outside temperature was a high of 34'F at the time of this incident. On 7/12/2021 at 1:41pm, progress notes in resident 2's record has that resident 2 ? was found outside on the main highway by one of her family members. The family member called the Community to notify staff and staff was able to retrieve resident safely and return her back to the community?. The outside temperature was between 88'F and 91'F at the time of this incident. Additional evidence of violations for this standard are included in a word document.
Plan of Correction:	All residents have been reassessed to ensure proper placement within the community. Resident 2 and 3 have been relocated to MC. Resident 1 has been issued a d/c notice. Facility scheduled to enhance door alarm system to set at a specific time daily to ensure proper security 8/4/21. Due to Covid outbreak this was delayed. Scheduled to be completed by 9/10/21 Person responsible: RCD, ED and Maintenance Director