VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Fredericksburg
1001 Northside Drive
Fredericksburg, VA 22405
(540) 374-8200

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: April 5, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

Date of Inspection: April 5 and 8, 2022 Type of Inspection: Monitoring Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 25 Number of records reviewed and interviews conducted- 4 resident records and 2 staff records, 5 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). The residents were observed during activities. The Licensing Inspector reviewed the fire drills, dietician report, pharmacy review, resident council minutes and health care oversight.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on resident record review and staff interview, it was determined that the facility failed to obtain a completed physical examination from an independent physician as required. Evidence: Resident Bs physical examination report dated January 21, 2022 was not filled out as required.
Plan of Correction:	All physical examinations will be completed fully for admission of a resident to the facility. Nursing will audit the records to ensure compliance.
Standard #:	22VAC40-73-990-B
Description:	Based on facility records review and staff interview, it was determined that the facility failed to review the plan for resident emergencies with staff as required. Evidence: There was no documentation of a review of the plan for resident emergencies with staff every six months as required. The last review was dated April 22, 2021. There was no subsequent documentation for all staff.
Plan of Correction:	All facility staff will review the plan for resident emergencies as required. All documentation will be up to date.