VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Kilmarnock
460 S. Main Street
Kilmarnock, VA 22482
(804) 435-9896

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: April 20, 2022

Complaint Related: Yes

Comments:

An unannounced onsite complaint investigation was conducted on 04/20/2022. The allegations made against the facility is in regards to resident care and related services. The inspector interviewed staff and residents and reviewed facility records regarding the allegations made against the facility. A lunch time meal was observed. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Please contact me at Angela.r.reaves@dss.virginia.gov or (804) 840-0253 if you have any questions.

Violations:

Standard #:	22VAC40-73-440-H
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted the licensee has failed to ensure that a reassessments due to a significant change in the resident's condition, using the UAI, was utilized to determine whether a resident's needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: Resident #1-Documented date of admission 10/31/2016 The facility assessed the resident on 03/15/2020 as needing Mechanical and human help with Bathing, Toileting and Transferring. The resident was also assessed as needing physical assistance with Dressing and human help with eating/feeding. Facility records submitted for the inspector?s review notes that the resident was discharged back to the facility on 01/25/2021 after a seven day hospital admission. Facility records submitted for the inspector?s review noted that the facility did not reassessed resident #1 until 03/19/2021; fifty three days after the 01/25/2021 hospital discharge. On 03/19/2021 facility staff reassessed resident #1 noting that the resident is totally dependent with bathing, dressing, toileting and transferring and that these tasks will be performed by others. Upon request the facility did not submit for the inspectors review facility documentation that the resident was reassessed upon his return to the facility to determine appropriateness of placement.
Plan of Correction:	FACILITY'S RESPONSE- "Executive Director counseled Resident Care Director and Assistant Resident Care Director on ensuring that residents are reassessed upon return from a hospital visit. Resident Care Director understands the importance of ensuring that when assessments occur, that they are accurate with descriptions on specifically what type of mechanical or human help is needed. Resident has a current updated and accurate plan of care. This reoccurrence will be prevented by ensuring that all Care Plans and ISP's are updated upon residents return from hospital as indicated and needed. "
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that Individualized service plans were reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. ? Since 03/15/2020 to 03/18/2022 the facility has assessed the resident as needing human help with eating/feeding. The resident?s Individualized Service Plans (ISPs) beginning March 2020-March 18, 2022 notes in part that facility direct care staff are to monitor the resident during meal times and that the goal for the resident is to remain independent with eating/feeding. The facility did not submit upon request documentation that the resident?s ISP had been updated to note guidance for the facility?s direct care staff to implement that ensured the resident received human physical help during meal times. ? The resident?s physician assessed the resident on 01/29/2021as needing his legs elevated and also noted dehydration and that the resident was receiving home health wound care services. The resident?s Individualized Service Plans (ISPs) beginning 03/18/2021-03/19/2022 is not updated to note guidance for the facility?s direct care staff to implement that ensured the residents? legs were elevated and that identified a hydration plan for facility staff to implement based on the resident?s assessed needs.
Plan of Correction:	FACILITY'S RESPONSE -"Executive Director counseled Resident Care Director and Assistant Resident Care Director on ensuring that residents are reassessed upon return from a hospital visit. Resident Care Director understands the importance of ensuring that when assessments occur, that they are accurate with descriptions on specifically what type of mechanical or human help is needed. Residents' current ISP and care plans states that he is on a mechanical soft diet and does need supervision and assistance from support staff while eating. Resident is able to feed himself but staff are able to provide supervision in case assistance is needed to ensure that the resident is not "pocketing" his food. Resident has a current updated and accurate plan of care. This reoccurrence will be prevented by ensuring that all Care Plans and ISP's are updated upon residents return from hospital as indicated and needed. Resident care plan is updated as of 03/19/2022. Resident is encouraged to elevate legs when needed. Resident care director will closely monitor this resident for any changes regarding hydration.?
Standard #:	22VAC40-73-460-A
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted the licensee has failed to assume general responsibility for the, safety, and well-being of the residents. Evidence: Resident #1-Documented date of admission 10/31/2016 ? 12/24/2021: Facility staff #1 documented on the facility?s Progress Notes- resident #1 identified ?laying in bed on his back throwing up and trying to catch his breath. resident also has loose stools and a cough?. The current facility Administrator and the Director of Nursing clarified that facility staff #1 is a registered medication aide. Facility staff #1 does not possess the skill set to make resident assessments based on her interaction with the resident. Upon request the facility did not submit for the inspector?s review facility documentation that the resident was assessed based on the documented observation and interaction that facility staff #1 had with resident #1 on 12/24/2021. The facility?s Progress Notes document revealed that the resident was sent out from the facility to a local hospital for emergency medical intervention on 01/19/2021 and returned seven days later on 01/25/2021. Facility staff also documented prior to the resident being transported for emergency medical intervention that the resident had ?Poor fluid and food intake noted for a couple of days?. Facility staff are not maintaining appropriate resident documentation based on the resident?s assessed and observed incidents/ needs and are not documenting follow-up contact with the resident?s physician regarding appropriate service delivery.
Plan of Correction:	FACILITY RESPONSE- "Resident Care Director provided staff with training regarding the importance of thorough and accurate documentation. Executive director also provided the Resident care director with the mportance of providing the residents with an accurate assessment when changes occur regarding the resident's overall health and safety. Resident care director understands the importance of ensuring that the residents are provided with an accurate assessment at all times. Resident is observed daily for any changes and dietary intake changes."