VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at King's Grant House
440 North Lynnhaven Road
Va. beach, VA 23452
(757) 431-8825

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: June 29, 2022 and July 7, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/29/2022 from 8:28 am to 3:40 pm and 7/7/2022 from 9:44 am to 12:40 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 52 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 An exit meeting will be conducted to review the inspection findings. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-310-H
Description:	Based on record review, the facility admitted and retained individuals with prohibited conditions or care needs. Evidence: 1. Resident #3 admitted to the facility on 09-21-2021. The physical examination and report for Resident #3 (dated on 9/08/21) indicates the resident requires continuous licensed nursing care.
Plan of Correction:	PCP to reassess resident #3 for appropriateness to retain resident. Re educate Executive Director, Resident Care Director, and Sales Director on Regulation 310-H. Audit current resident H&P to ensure compliance. Resident Care Director or designee will verify Health & Physical Report to ensure compliance prior to admission to community.
Standard #:	22VAC40-73-325-A
Description:	Based on record review, the facility failed to ensure for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating be completed. The facility also failed to ensure that a fall risk rating was completed after a fall. Evidence: 1. Upon review of the resident?s record, Resident #7 (admitted 5/20/22) meets the criteria for assisted living care and has falls documented in progress notes on 5/28/22 and 6/18/22; however, there was no documentation of a fall risk rating being completed in the resident?s record.
Plan of Correction:	Fall Risk Rating completed for resident #7. Reeducate Resident Care Director on regulation 325-A. Resident Care Director or designee to complete a Fall Risk Rating on each resident after each fall.
Standard #:	22VAC40-73-440-A
Description:	Based on record review, the facility failed to ensure the UAI for residents be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition. Evidence: 1. Resident #2 admitted to the facility on 02-11-2022; however, the UAI in their record was dated 03-23-2022 and not signed for approval by the administrator or designee. 2. Resident #4 admitted to the facility on 11-01-2021; however, the UAI in their record was dated 11-18-2021.
Plan of Correction:	Reeducate Resident Care Director on regulation 440-A. Resident Care Director or designee to ensure UAI is completed and signed at admission for each resident. Audit all admission UAI?s to ensure compliance.
Standard #:	22VAC40-73-720-A
Description:	Based on record review, the facility failed to ensure a valid written Do Not Resuscitate (DNR) order has been issued by the resident's attending physician; and that the written order is included in the individualized service plan. Evidence: 1. Upon review of Resident #6?s record, there are inconsistencies in regards to the resident?s code status. The Durable DNR order in the resident?s record is dated 9/13/21.The ISP (dated 6/23/22) for Resident #6 indicates the resident?s code status is a Full Code. 2. Upon review of Resident #7?s record, the ISP (dated 5/20/22) indicates the code status of the resident as a DNR. The resident does not have a signed DNR order or Durable DNR in their record.
Plan of Correction:	Verified and obtained DNR or Full Code for residents #6 and #7. Resident Care Director or designee to obtain either DNR or Full Code for each new admission upon admission. Audit current residents code to ensure compliance.
Standard #:	22VAC40-90-40-H
Description:	Based on record review, the facility failed ensure any person employed does not have a conviction of any of the barrier crimes. Evidence: 1. Staff #6 was hired on 12-07-2021 and working the floor 06-29-2022. A criminal history record report for Staff #6 was completed on 12-08-2021. The criminal history record report indicates Staff #6 was convicted of a misdemeanor barrier crime on 08-02-2021.
Plan of Correction:	Removed staff #6 from the schedule until criminal background check is clear. Reeducate Executive Director and Business Office Manager on regulation 40-H. Audit current staff background checks to ensure compliance. Business Office Manager or designee will verify criminal background checks prior to hire.