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: June 16, 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

Comments:

Type of inspection: Renewal On-site renewal inspection conducted two days, 5-5-22 and 5-6-22 (Ar 07:30 /dep 6:45 p.m.) The facility census was 50S, a tour of the facility was conducted, medication pass observation, activity, emergency preparedness/ first aid kit check, resident and staff records and interviews conducted. A preliminary exit conducted with the facility representative on 5-5-22. On 5-6-22 a preliminary exit was conducted with the Administrator with a request for additional documents. Documents were received on 5-12-22. A preliminary was conducted on 5-25-22 with the Administrator, the resident care coordinator, assistant to the Administrator and the Business office manager and additional documents requested. Requested documents received on 5-25-22. The final exit conducted with administrator and renewal reports provided on 6-9-22 The Acknowledgement of Inspection form was sent to the Administrator following each exit meeting. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Willie Barnes), Licensing Inspector at (757-439-6815) or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure staff attend at least 12 hours of annual training, at least two of the required hours of training shall focus on infection control and prevention. When adults with mental impairments resident in the facility, at least four of the required hours shall focus on topics related to residents? mental impairments for one of three staff records reviewed. Evidence: 1. On 5-6-22, staff #1?s record reviewed with staff #3 did not include training hours. On 5-12-22, a staff document with training information was received. However, the annual training hours based on staff?s date of hire of 11-11-19 was not met. The required infection control and mental health training hours were also not met. 2. Staff #1 acknowledged the aforementioned staff member did not have required annual training.
Plan of Correction:	ED will ensure courses are within the Nov-Nov timeframe Person Responsible: ED Due Date: November 11, 2022
Standard #:	22VAC40-73-220-B
Description:	Based on observation, record reviewed and interviews, the facility failed to ensue when private duty personnel who are not employed by a licensed home care organization provide direct care or companion services to residents in an assisted living facility, the requirements of the regulation 22VAC40-73-A would be required in addition other requirements of the regulation. Evidence: 1. On 5-5-22 during interview with #interviewee #11, the individual stated providing care such as bathing, dressing, transferring, and toileting for resident #1. Individual stated being the resident?s private care giver. 2. On 5-6-22, interview with staff #1, request for caregiver?s information was requested. The information for caregiver was not available. 3. On 5-12-22, the inspector received the facility?s sitter agreement with the resident?s representative. The date of the contract was 5-12-22 and noted that the private duty caregiver was an employee of the assisted living facility, staff?s date of hire 1-10-22. 4. On 5-25-22, during interview with staff #1, the inspector was informed the caregiver was employed PRN with the assisted living. 5. Staff #1 acknowledged the aforementioned resident?s private caregiver is an employee of the facility and provides private duty care for a resident at the facility where the caregiver is also employed. The facility did not have documentation of private caregiver documents prior to 5-12-22.
Plan of Correction:	Required paperwork and sitter agreement for resident #1 has been obtained, RCD will generate a list of all private duty employees monthly. BOM/ED will ensure required paperwork complete Person Responsible: RCD/ED/BOM
Standard #:	22VAC40-73-260-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure each direct care staff member shall maintain current certification in first aid. Each direct care staff member who does not have current certification in first aid shall receive certification within 60 days of employment. Evidence: 1. On 5-6-22 staff member #7?s record did not include documentation of receiving first aid within 60 days of employment. Staff?s record documented a date of hire date of 3-15-22. 2. Staff #3 acknowledged the aforementioned staff?s record did not have the required first aid certification as required.
Plan of Correction:	Staff member #7 completed CPR/First Aid class held at the community 6/10/22 BOM will audit employee files to ensure compliance. CPR/First Aid classes to be held quarterly and as needed to ensure all staff are compliant. Person Responsible: BOM
Standard #:	22VAC40-73-290-A
Description:	Based on document and staff interviewed, the facility failed to ensure the written work schedule includes the names and job classification of all staff working each shift, with an indication of whomever is in charge at any given time. Evidence: 1. The concierge schedule received on 5-6-22 only the first name of staff documented. 2. The following schedules received on 5-12-22: (a) housekeeping and programing staff- first name only and (b) management and kitchen/dietary schedule did not include staff position and first name only. 3. Staff #1 acknowledged the facility staff schedules did not include all required information.
Plan of Correction:	Current schedules amended to include first name, last name and job classification. Department heads will be educated on the requirements. All schedules will include required information. Person Responsible: ED will review schedules monthly to ensure compliance.
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure in accordance with 63.2-1805- D of the Code of Virginia, it did not admit or retain individuals with any of the prohibited conditions or care needs for two residents. Evidence: 1. Resident #2?s record included prescriber?s orders dated 3-29-22 for the following psychotropic medications, Haloperidol and Lorazepam. On 5-6-22, the resident?s record did not have a treatment plan for these medications. 2. Resident #3?s record included prescriber?s order dated 3-4-22 for Haloperidol. On 5-6-22 the resident?s record did not have a treatment plan for this medication. 3. Staff #1 acknowledged the aforementioned resident?s record did not have a psychotropic treatment plan for the aforementioned psychotropic medications.
Plan of Correction:	RCD/ARCD or designee to ensure the Psychotropic Medication Diagnosis and Plan of Care is complete for resident #2 and #3. RCD/ARCD will ensure Psychotropic Medication Diagnosis and Plan of Care is completed by physician before residents' admission to community. Chart audit to be performed on existing residents to ensure compliance with regulation. RCD and ARCD education on regulation. RMAs will be education on regulation and form to be obtained with psychotropic orders. Person Responsible: RCD/ARCD or designee
Standard #:	22VAC40-73-320-A
Description:	Based on observation, document reviewed and staff interviewed, the facility failed to ensure the resident?s admitting physical examination included all information required per the regulation for two residents. Evidence: 1. Resident 1?s admitting physical examination dated 2-22-22 documented that the resident is ambulatory. During interview with resident, the inspector observed the resident is non-ambulatory, resident does not walk, staff members utilizes a mechanical lift to transfer from bed to wheelchair. Resident stated resident is a double amputee. 2. Resident #2?s admitting physical examination dated 3-22-22 did not include the resident?s height and weight information. 3. Staff #1 acknowledged the aforementioned resident?s admitting physical examination document did not include all required information.
Plan of Correction:	H&P for resident #1 and #2 will be corrected. Chart audit will be completed to ensure that all H&P's are completed accurately. RCD/ARCD will review all H&P documents before admission to ensure compliance. Person Responsible: RCD or designee
Standard #:	22VAC40-73-380-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s personal and social information placed in resident?s record was kept current for four residents; Evidence: 1. On 5-6-22, resident #?2?s record included a copy of the resident?s ?Do Not Resuscitation (DNR)? document signed and dated 3-25-22 by the physician. The resident?s ISP dated 2-13-22 documented the resident as a ?Full Code?. The resident?s personal and social data document also noted resident as a ?Full Code?. 2. Resident #3?s record included a copy of the resident?s ?Do Not Resuscitation (DNR)? document signed and dated 9-15-20 and 1-11-21 by the physician. The resident?s personal and social data document advance directive information section is blank. Resident?s physical examination signed 9-2-20 documented resident is allergic to Sulfa-Thiazide diuretics-Acetazolamide. The social data did not include these items in the allergy section of the document. 3. Resident #5?s personal and social data document date of admission section was blank. 4. Resident #6?s personal and social data document date of admission and address was blank. 5. Staff #1 acknowledged the aforementioned residents? personal and social data document were not updated as required.
Plan of Correction:	Personal social data sheet for residents #2, #5 and #6 will be updated. Charts will be audited to ensure up to date information is reflected on the Personal Social Data sheets. Upon admission ED or designee will ensure the report is accurate and complete. RCD or designee will make changes as needed to ensure information is correct. Person Responsible: ED, RCD or designee
Standard #:	22VAC40-73-440-D
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure for private pay individuals, the uniformed assessment instrument (UAI) shall be completed as required by 22 VAC for two of six records reviewed. Evidence: 1. Resident #2?s uniformed assessment instrument (UAI) dated 1-28-22 (7-28-22) was completed by staff member, but not signed by a designee or administrator. 2. Resident #3?s UAI dated 3-11-21 was completed by staff member, but not signed by a designee or administrator. 3. Staff #1 acknowledged the aforementioned UAI was not completed as required.
Plan of Correction:	All UAI's to be audited and corrected to ensure that required signatures are obtained. Educate the RCD/ARCD or designee on required signatures on all UAIs per regulation. RCD/ARCD will review all UAI's with ED once completed to ensure compliance. Person Responsible: RCD, ED or designee
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessment needs for four residents. Evidence: 1. Resident #1?s preliminary plan of care dated 2-25-22 and individualized service plan dated 3-31-22 did not include resident?s pacemaker noted on resident?s physical dated 2-22-22. Interviews with resident, spouse and staff stated resident eats meals in room. This was not addressed on the ISP. Interview with private caregiver and resident and spouse, resident receives private duty services, this service was not on the ISP. The uniformed assessment instrument (UAI) dated 4-10-22 documented walking and stairclimbing need not performed, these needs were not addressed on the ISP (resident resides on the second floor of the facility). Resident?s physical examination dated 2-22-22 documented resident not capable of self-administration. Resident have medications at bedside in room and self-administers per interview with resident and spouse on 5-5-22. Resident?s physical documented resident?s fluid limit of 1200 ml, this was not documented on the ISP and resident was given an evening supplement drink but there was not on the ISP. 2. Resident #2?s UAI dated 1-28-22 (7-28-22) documented resident?s behavior as appropriate. The resident?s ISP dated 2-13-22 documented resident wanders and is resistive to care. Resident?s physical examination signed 1-3-22 documented the resident?s hearing loss, the ISP documented the resident does not have hearing impairment. Transferring need on UAI assessed as supervision, the ISP documented use of grab bars and verbal cues. Bathing assessed as supervision, the ISP documented use of shower bench, hand held shower and grab bars. Resident`s record documented a Do Not Resuscitate (DNR) order dated 3-25-22. The resident?s ISP documented the resident is a ?Full Code?. 3. Resident 3?s UAI dated 9-7-21, documented resident?s behavior as appropriate. The ISP dated 3-6-21 documented resident may wander outside; health or safety may be jeopardized, participant not combative about returning and ISP documented resident is resistant to care. Resident?s physical examination signed 9-2-20 documented the following allergy: Sulfa-Thiazide diuretics-Acetazolamide. The ISP dated 3-6-21 documented no know allergies. 4. Resident #5?s record did not include a comprehensive ISP. The preliminary ISP was dated 3-15-22 by facility staff. The resident?s date of admission was documented as 3-14-22.
Plan of Correction:	RCD or designee will ensure that UAI matches the ISP for resident $1, #2, #3 and #5. UAI and ISP's will be audited to ensure that ISP includes ass assessment needs. ED and RCD will review completed ISPs going forward to ensure all needs are included on ISP. Person Responsible: RCD/ARCD, ED or designee
Standard #:	22VAC40-73-450-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator or his designee, the person who has developed the plan, and the resident or the legal representative. Evidence: 1.On 5-6-22, resident #6?s preliminary plan of care was not dated any signed by the facility nor the resident or legal representative. The comprehensive plan dated 4-19-22 was not signed by the resident or legal representative.
Plan of Correction:	Resident is no longer in the facility. Current resident charts will be audited to ensure compliance. To ensure compliance RCD/ARCD and designee to be educated on the regulation. RCD/ARCD will ensure resident/legal representative signatures on all ISP's going forward. Person Responsible: RCD/ARCD or designee
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition for a resident. Evidence: 1. On 5-6-22, resident #3?s individualized service plan dated 9-7-21 documented an end date (review date) of 3-7-22. The ISP in the record was signed and dated by the developer, administrator and resident on 9-7-21. The resident?s record documented the date of admission was 9-14-20. 2. On 5-6-22, resident #4?s ISP dated 10-1-21 documented an end date (review) of 4-1-22. The record did not include a current ISP. The record documented the date of admission was 9-25-18.
Plan of Correction:	RCD/ARCD will complete ISP for resident #3 and #4 RCD/ARCD will complete monthly audit to ensure all ISP due are completed on time. Person Responsible: RCD/ARCD or designee
Standard #:	22VAC40-73-470-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure, either directly or indirectly, that the health care service needs of residents are met. Evidence: 1. On 5-6-22, resident #5?s physical examination dated 3-12-22 documented Physical Therapy (PT) and Occupational Therapy (OT) recommended. The resident?s record did not include documentation of physical therapy and occupational therapy evaluation and/or services provided. 2. Staff #1 acknowledged the aforementioned resident?s had not be evaluated for therapy services.
Plan of Correction:	RCD will obtain documentation of PT/OT services provided for resident #5 Upon admission, RECD/ARCD or designee will review any therapy orders on h&p, coordinate with the appropriate therapy group and ensure proper documentation is completed. Once completed, documentation will be place in resident chart. All third-party providers will be required to fill out Outside Agency service notes per company policy to ensure proper documentation is being completed. Responsible Party: RCD/ARCD or designee
Standard #:	22VAC40-73-650-A
Description:	Based on observation, record reviewed and staff interviewed, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the counter, and sample medications. Evidence: 1. On 5-6-22 during medication pass observation with staff #2 on the safe, secure unit, resident #7 was administered Cefdinir. The May 2022 medication administration record documented the resident started the medication 4-29-22 and was to be administered the medication for seven days. A request for the signed physician?s order was requested on 5-6-22 and 5-25-22, the signed physician?s orders received did not include this medication. 2. Resident #1 was observed with the following medications, treatment in the room during interview on 5-5-22: Calmoseptine, perineal solution and Nystatin topical cream. Resident did not have a signed and dated physician?s order for these items located at bedside. The uniformed assessment instrument documented resident?s medication are administered by staff and the admitting physical documented resident not able to self-administer.
Plan of Correction:	Resident #1 and spouse will be educated on the importance of facility staff to administer all medications, including over the counter medications. MD will be notified of incorrect start/stop date for resident #7 antibiotic order. RCD/ARCD will complete room walkthroughs to ensure compliance. Educated RCD/ARCD on the importance of orders having the correct start/stop dates. If not correct, contact physician for updated order. Person Responsible: RCD/ARCD or designee