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: May 5, 2022 and May 6, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint On 5-5-22 and 5-6-22 an unannounced complaint inspection was conducted. A complaint was received by VDSS Division of Licensing on 5-5-22 regarding allegations in the areas of staffing and resident care needs. The facility census was 50. There were two residents interviewed and four records reviewed in conjunction with the renewal inspection that was being conducted. No staff records reviewed for the complaint but were reviewed for the renewal inspection, the purpose of the visit. An exit meeting was conducted with the facility representative on 5-5-22, with the administrator on 5-6-22. The Acknowledgement form was sent via email following the preliminary exit on 5-6-22 and the final exit with inspection reports on 6-9-22. The evidence gathered during the investigation supported the allegation of staffing and resident care of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-280-A
Complaint related:	Yes
Description:	Based on documents reviewed and interviews, the facility failed to ensure it had staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with the regulation. Evidence: 1. On 5-5-22 during a complaint inspection, the facility staffing scheduled for May 4, 2022 documented staff members #5 scheduled (3 pm-11pm); staff #6 scheduled (11pm-7 am) and staff #7 scheduled (7pm- 7am). Interviews with resident and staff members on 5-5-22 revealed staff #5 came to work but did not stay. The facility time sheet documented staff #5 clocked in at 6:13 pm and clocked out at 9:11 pm. Staff #6 and #7 showed not clocked in time. Interviews with resident #1 and staff #2 and #4, stated the staff members did not report to work on 5-4-22. 2. Interview with resident #1, the resident needed assistance in going to bed and with Oxygen on the evening of 5-4-22, however, there was no staff on the unit to assist the resident in transferring to bed and switching the Oxygen from the portable supply to the concentrator in the room. The resident?s record included a signed order for Oxygen 2L via nasal cannula (NC)-continuous. The ISP documented resident?s oxygen use required hands on assistance, staff to check NC for correct position and check portable tank and check concentrator. Resident contacted the concierge?s desk to request assistance for care. The concierge (staff #9) provided assistance, however, this individual is not hired as a direct care staff with the facility. 3. Interviews with other staff members stated there were other resident?s on the Assisted Living Unit on the second floor who required supervision due to wandering, two person assistance and other care needs. A review of resident #2, #3 and #4?s record documented resident?s specialized needs. Resident #2?s UAI dated 4-1-22 assessed as a two ?person assist, activities of daily living performed by others. Resident #3?s physical dated 3-22-22 documented resident not able to recognize danger or protect own safety. Resident was observed on 5- and 5-6-22 and safety concerns observed. Observation and interview with resident #4, resident is a double amputee and requires staff assistance with transferring and does not walk. 4. Staff #1 acknowledged the facility did not have sufficient qualified staff on duty to provide resident care services.
Plan of Correction:	Since 5/5/22 10 additional resident care employees have been hired. Additionally, facility is working with staffing agencies to schedule appropriate number of staff. Facility will continue to prioritize recruitment and hiring of care staff. ED or designee will review schedule weekly to ensure proper staffing numbers. Person Responsible: ED/RCD/ARCD or designee
Standard #:	22VAC40-73-380-B
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s personal and social data form was kept updated for a resident. Evidence: 1. On 5-5-22, resident #1?s record included a Do Not Resuscitate Order dated and signed by the physician on 1-9-20. The social data documented resident is a Full Code. 2. Staff #1 and #2 acknowledged the aforementioned resident?s personal and social data form was not updated.
Plan of Correction:	Resident #1 Social Data form corrected to ensure accurate information. RCD/ARCD were educated about the importance of keeping the Social Data sheets updated. Audit of all Social Data sheets will be performed to ensure compliance. Person Responsible: RCD/ARCD or designee RCD or designee will complete audit of 5 resident Personal Social Data sheets per week until completed.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on observation, record reviewed and interviews, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for a resident. Evidence: 1. On 5-5-22, the inspector observed 2 bottles of Flonase nasal spray on the dresser. Biotene oral rinse, Ketoconazole cream and Nyamyc powder were observed on the bathroom counter. The resident?s uniformed assessment instrument dated 12-24-21 documented medication is administered by facility staff. The ISP dated 12-26-21 documented resident unable to self-administer medication. The resident?s record included a signed physician order dated 12-13-21 to self-administer Ketoconazole cream and Calmoseptine. 2. The resident?s discharge order dated 3-21-22 documented resident?s diet as low-salt cardiac. The ISP documented as No Concentrated Salt (NCS). A review of the dietary order in the kitchen with staff #5, the resident?s diet be prepared was NCS. 3. The uniformed assessment instrument (UAI) dated 12-24-21 assessed stairclimbing as not performed. The ISP dated 12-24-21 did not address the need. Resident resident?s on the second floor of the facility and walking is assessed as not performed with use of wheelchair and physical assistance for transferring. 4. Staff #2 acknowledged the aforementioned resident?s ISP did not address all required needs.
Plan of Correction:	UAI/ISP updated to reflect self-administer medication order for the medications at bedside. RCD/ARCD to review charts of all residents with self-administer orders to ensure that UAI/ISP reflect correctly. Person Responsible: RCD/ARCD or designee
Standard #:	22VAC40-73-690-G
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it took action in response to the recommendations noted in the pharmacy review report to the facility as required per the regulation. Evidence: 1. On 5-5-22, resident #1?s pharmacy review dated 11-15-21 recommended resident have lab work completed. The pharmacy review completed March 2022 recommended lab work since lab-work had not been completed in over a year. The record included a physician?s order dated 3-24-22 for lab work to be conducted. The last lab work in the record was dated 2-9-21. 2. Staff #2 acknowledged the aforementioned resident?s lab work was not conducted.
Plan of Correction:	RCD will inquire with resident #1's physician whether lab work has been completed. If labs were not completed in outside PCP office, facility will obtain new orders to complete lab draw. RCD/ARCD or designee will ensure that the pharmacy recommendations are forwarded to the appropriate physician and any future orders will be completed. Person Responsible: RCD/ARCD or designee