VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Stafford
30 Kings Crest Drive
Stafford, VA 22554
(540) 288-9353

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: June 13, 2022 and June 17, 2022

Complaint Related: No

Areas Reviewed:

Administrative and Administrative Services Personnel Staffing and Supervision Admission, Retention and Discharge of Residents Resident Care and Related Services Resident Accommodations and Related Provisions Buildings and Grounds Emergency Preparedness Mixed Population Secured Unit

Comments:

Date of Inspection: June 13 and June 17, 2022 10am-1pm Type of Inspection: Monitoring inspection If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@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 45 Number of records reviewed and interviews conducted- 10 records, 4 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 completed corrective action needs to be in the licensing office by July 1, 2022

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on staff record review and staff interview, it was determined that the facility failed to maintain current first aid documentation within the staff record as required. Evidence: Staff C had no current documentation of the first aid certificate within the record as required.
Plan of Correction:	Staff member C?s First Aid training is scheduled for 7/18/22. The BOM/Designee has audited all direct care staff records for documentation of current First Aid certification. All direct care staff will have current First Aid certification by 7/30/22. The Resident Care Director (RCD) will schedule quarterly First Aid classes for staff participation on a quarterly basis, ongoing. The BOM will provide a list of those staff members requiring re-certification for enrollment. Classes for the next four (4) quarters will be scheduled by 7/22/22. The BOM will create a tracking system to monitor the date of First Aid certifications and expiration dates for all direct care staff by 7/14/22. The ED/Designee will audit all direct care staff records quarterly for current First Aid certification for four (4) quarters to ensure compliance.
Standard #:	22VAC40-73-320-B
Description:	Based on resident record review and staff interview, it was determined that the facility failed to have documentation of an annual risk assessment for tuberculosis for residents as required. Evidence: Resident A, B and C had no documentation in the records of an annual risk assessment for tuberculosis as required.
Plan of Correction:	The RCD/Designee completed TB Screens for residents A, B, and C on 6/29/22. The RCD/Designee will audit records for all other resident to ensure TB Screens are current, and update Screens as needed by 7/15/22. The RCD will enter the dates of the TB Screens into the electronic medical record system to track due dates. The RCD will run the Annual TB Screening Documentation report for TB Screens at the end of each month to determine Screens due. The ED will monitor the Annual TB Screen Documentation Report monthly for three (3) months to ensure all screens are current.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, it was determined that the facility failed to complete a comprehensive Individualized Service Plan (ISP) within 30 days of admission as required. Evidence: Resident C had no documentation within the record of a 30 day comprehensive ISP as required.
Plan of Correction:	The RCD will complete Resident C?s comprehensive ISP by 6/30/22. The RCD/Designee will review all resident?s records to ensure completion of a comprehensive ISP. Residents without comprehensive ISPs will be reassessed, and comprehensive ISPs completed by 8/15/22. The RCD will review the electronic medical record Assessment Due Date Report weekly and complete assessments due the next week on-going. The ED will run the Assessment Due Date Report monthly for three (3) months to ensure all initial comprehensive ISPs have been complete within 30 days of admission.
Standard #:	22VAC40-73-450-D
Description:	Based on resident record review and staff interview, it was determined that the facility failed to have a coordinated plan of care between the facility and the hospice agency. Evidence: Resident D had no documentation in the record of a coordinated plan of care between the facility and the hospice agency indicating what care was being delivered to the resident.
Plan of Correction:	The RCD will meet with the assigned hospice nurse for Resident D to create a coordinated plan of care, with necessary ISP updates completed by 7/15/22. The RCD will meet with the hospice agencies for all other residents on caseload will to ensure each resident has a coordinated plan of care and complete any necessary ISP updates to demonstrate a coordinated plan of care by 7/31/22. The RCD will schedule ongoing bi-weekly (every 2 weeks) meetings with all hospice agencies with community residents on caseload to ensure each resident a coordinated plan of care indicating current care provided to the resident, and the resident?s community ISP updated as needed. The ED will audit the records of two (2) residents on hospice caseload monthly for three (3) months to ensure there is a coordinated plan of care that reflects the current care provided to each resident.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and staff interview, it was determined that the facility failed to update the Individualized Service Plan (ISP) as needed to a change in resident condition. Evidence: Resident B had no documentation to reflect a protocol for heel wound care. Resident D had no documentation to reflect a protocol for hip wound care.
Plan of Correction:	The RCD/Designee will update Resident B?s ISP to reflect the current protocol for heel wound care, and resident D?s ISP to reflect the current protocol for hip wound care by 6/30/22. The RCD/designee will review the ISPs for all community residents receiving wound care to ensure the resident?s ISP reflects the current wound care protocols. The RCD will meet with all outside agency nurses providing wound care to discuss wound progress and current treatment regimens and will update the resident?s ISP as needed. The ED will review the records of one (1) resident receiving outside agency services for wound care monthly to ensure the resident?s ISP reflects the current wound care protocol for three (3) months.
Standard #:	22VAC40-73-710-B
Description:	Based on resident record review and staff interview, it was determined that the facility used restraint equipment for residents in care. Evidence: Resident A, B and C had grab bars for positioning attached to the beds. The residents have serious cognitive impairment and are not able to safely use these devices for positioning.
Plan of Correction:	The grab bars attached to the beds of residents A and C were removed from their beds by 6/30/22; resident B did not have side rails/grab bars attached to the bed. The RCD/ED will meet with the responsible parties for the residents to advise them that the positioning rails removal based on the resident?s inability to use the devices safely based on serious cognitive impairment. The RCD/Designee will audit all resident beds for bedrails/grab bars. Safety assessments for any resident observed with bedrails/grab bars will completed or the devices removed by 7/15/22. Any resident assessed as safe to use the bedrails/grab bars for positioning will have an order for the devices, and their ISP updated to reflect the use of the devices and the position of the devices when not in use. The RCD/Designee will notify the responsible persons for those residents who have their bedrails/grab bars removed. The RCD will audit for bedrails/grab bars attached to resident beds monthly ongoing for the next twelve (12) months to ensure ongoing compliance.