VIRGINIA DEPARTMENT OF SOCIAL SERVICES

COMMONWEALTH SENIOR LIVING AT HAMPTON
1030 TOPPING LANE
Hampton, VA 23666
(757) 826-3728

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: June 30, 2022 , July 1, 2022 , July 11, 2022 and July 14, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-80 THE LICENSE

Comments:

Type of inspection: Renewal An unannounced on-site renewal inspection was conducted by two inspectors on 6-30-22 (07:35 a.m./dep 19:15 p.m) and 7-1-22 (AR 09:20 a.m./dep 14;20 p.m). The facility census on 6-30-22 was 84. A tour of the facility was conducted, medication pass conducted, emergency preparedness conducted, breakfast meal observed on day one in the assisted living and safe, secure unit, activity observed, staff and resident interviews conducted and staff and resident records reviewed. The Acknowledgement of Inspection form was sent via email following each on-site visit and documents received and preliminary exits conducted with the Administrator. An exit meeting will be conducted to review the inspection findings on 7-22-22. 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 #:	22VAC40-73-220-A
Description:	Based on document reviewed and staff interviewed, the facility failed to document on the resident?s individualized service plan (ISP) the direct care or companion services provided by private duty personnel. Evidence: 1. On 6-30-22, resident #7?s individualized service plan (ISP) dated 5-9-22 did not include the services provided by the private duty personnel. 2. On 6-30-22 and 7-14-22, staff #1 acknowledged the private duty services for the aforementioned resident was not document on the ISP.
Plan of Correction:	What Has Been Done to Correct? All additional services provided by private duty personnel were added to the residents? ISP. How Will Recurrence Be Prevented? ED and RCD will verify additional services provided by private duty personnel are listed if they apply. Person Responsible: ED, RCD, and or Designee Due Date: 07/01/2022
Standard #:	22VAC40-73-260-C
Description:	Based on observation and staff interviewed, the facility failed to ensure the listing of all staff who have current certification in first aid or CPR was posted in the facility so that the information was readily available to all staff at all times. Evidence: 1. On 6-30-22 during a tour of the facility with staff #3, a request was made to see the first aid/ CPR listing of staff. Staff #3 asked where it should be posted and stated, the listing was not posted. 2. On 6-30-22, staff #1 and #3 acknowledged the current listing of staff certified in first aid or CPR was not posted in the facility as required.
Plan of Correction:	What Has Been Done to Correct? Community posted the staff CPR list in both breakrooms. How Will Recurrence Be Prevented? ED, RCD, and or Designee will ensure CPR is posted and current. Person Responsible: ED, RCD, and or Designee Due Date: 07/01/2022
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) is completed as required. Evidence: 1. On 6-30-22, resident #2?s uniformed assessment instrument (UAI) dated 12-24-21 was not signed by the administrator or designee of the facility, when the assessor is a facility staff member. The document was signed by the resident?s legal representative. 2. Resident #4?s UAI dated 7-3-22 was signed by the resident?s legal representative. 3. On 7-1-22, resident #1?s UAI dated 2-16-22 was not signed by the administrator or designee when the assessment is completed by a facility staff member. 4. On 6-30-22, 7-1-22 and 7-14-22, staff #1 acknowledged the aforementioned resident?s UAI did not included the required signatures.
Plan of Correction:	What Has Been Done to Correct? Missing signature was added to completed UAI. How Will Recurrence Be Prevented? ED, RCD, and or Designee will ensure all required signatures prior to filling. Person Responsible: ED, RCD, and or Designee Due Date: 07/01/2022
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 assessed needs. Evidence: 1. On 6-30-22, resident #3?s uniformed assessment instrument (UAI) dated 6-7-22 documented bathing need as human help/physical assistance. The ISP documented resident needed a shower chair during bathing. The UAI documented no help needed for transferring. The ISP documented resident required hands on assistance with transferring and the change position. Eating/feeding need documented mechanical help/human help (supervision). The resident was observed being spoon-fed by staff. Staff #5 stated resident required staff to assist with meals. The ISP did not documented the about of time to feed and did not document staff to spoon feed resident. Wheeling need was documented as mechanical help/human help (physical assistance) and stairclimbing documented as not performed; wheeling and stairclimbing were not documented on the ISP. The resident?s need for assistance with money management was documented as no help, the ISP documented resident has a POA who assistance because resident is unable to handle financial business. 2. Resident #4?s UAI dated 7-3-22 documented toileting need as human help/physical assistance. The ISP dated 3-2-22 documented resident uses adult briefs. Transferring need documented mechanical help on the UAI, the ISP documented resident does not require assistance.
Plan of Correction:	What Has Been Done to Correct? Community added who will be managing residents? finances to individualized service plan. How Will Recurrence Be Prevented? RCD will verify and document who is handling residents? finances. Person Responsible: ED, RCD, and or Designee Due Date: 07/01/2022
Standard #:	22VAC40-73-660-A
Description:	Based on observation and staff interviewed, the facility failed to ensure that medication and dietary supplements prescribed and administered by the facility were stored in a manner consistent with current standards of practice. Evidence: 1. On 6-30-22 during a tour of the facility, the inspectors observed the door to the staff lounge located behind the unmanned nursing station was open. Upon entering the lounge, the inspectors observed open cases of nutritional supplements labeled with various resident?s name. 2. Staff #5 acknowledged the door was unlocked and open to the public. Staff #3 stated the door should be closed.
Plan of Correction:	What Has Been Done to Correct? Community has stored all dietary supplements in a manner consistent with current standards of practice. How Will Recurrence Be Prevented? Staff will be trained on where dietary supplements are to be stored going forward. Person Responsible: ED, RCD, and or Designee Due Date: 07/01/2022
Standard #:	22VAC40-73-680-C
Description:	Based on observation and staff interviewed, the facility failed to ensure medications shall be administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule. Evidence: 1. On 6-30-22 during a check of the medication cart with staff #4 at 10:32 a.m., there were ten residents on the Langley Unit whose medication had not been administered. The ten residents? (LL 1-10) medication was scheduled for 9:00 a.m. 2. Staff #4 acknowledged there were medications to be administered past the facility?s scheduled dosing time.
Plan of Correction:	What Has Been Done to Correct? RCD has assessed the current medication pass, spoke with resident PCP to adjust times. How Will Recurrence Be Prevented? RCD will continue to evaluate medication times to ensure they balance. Person Responsible: ED, RCD, and or Designee Due Date: 08/01/2022
Standard #:	22VAC40-73-860-J
Description:	Based on observation and staff interviewed, the facility failed to ensure cleaning supplies or other hazardous materials are stored in a locked area. Evidence: 1. On 6-30-22 during a tour of the facility, the housekeeping room door (across from room 210), was not was properly closed and was able to be opened by the inspector. The items observed in the housekeeping room/closet were Raid bug defense, glass cleaner, three bottles of lavender scented cleaner. Residents with cognitive impairment were observed on the unit (mixed population). 2. On 6-30-22, staff #10 acknowledged the door was not properly closed, therefore the cipher lock was not activated which would have locked the door when properly closed. 3. Shampoo and body wash was observed on the bathroom sink in room #510 on the safe, secure unit during the inspector?s tour with staff #10. Staff #10 acknowledged the items were present and no staff was in the room. 4. The storage closet door across from rooms #705 and #706 on the safe, secure unit was unlocked. Staff # 15 acknowledged the storage room door was not locked.
Plan of Correction:	What Has Been Done to Correct? Staff has been educated on ensuring doors are securely closed prior to leaving the immediate area. How Will Recurrence Be Prevented? Staff has been educated on ensuring doors are securely closed prior to leaving the immediate area. Person Responsible: ED, RCD, and or Designee Due Date: 07/01/2022
Standard #:	22VAC40-73-870-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the interior and exterior of the building was maintained in good repair and was kept clean. Evidence: 1. On 6-30-22 during a tour of the facility, the crown molding on the wall in the safe, secure unit (female side), near the exit door to the patio was observed to be cracked and missing a portion approximately 4 inches (height) by 10 inches (length). The toilet paper holder in the common area bathroom on the Canon unit (safe, secure unit) was missing. Also the light sensor in the common use bathroom did not work as designed, it did not come on when the inspector and staff entered the bathroom. The call bell system on the Canon (safe, secure unit was not operable. 2. The ceiling tile on the Ft Eustis unit was missing near room #202. 3. Staff #10 acknowledged the aforementioned items and areas of the building were not in good repair.
Plan of Correction:	What Has Been Done to Correct? Crown molding was fixed, and ceiling tile put back in place by Maintenance Director. How Will Recurrence Be Prevented? MD will complete one project prior to starting another. Person Responsible: ED, MD, and or Designee Due Date: 07/01/2022
Standard #:	22VAC40-73-960-B
Description:	Based on observation and staff interviewed, the facility failed to ensure the fire and emergency evacuation drawing was posted in a conspicuous place on each floor of each building used by residents. Evidence: 1. On 6-30-22 during a tour of the facility, the fire and emergency evacuation drawing was not posted on the Canon unit of the safe, secure unit. 2. Staff #10 acknowledged the evacuation drawings were not posted on the aforementioned unit.
Plan of Correction:	What Has Been Done to Correct? Community added additional evacuation drawings to each floor of the building used by residents. How Will Recurrence Be Prevented? MD will ensure all evacuation postings are on each floor used by residents. Person Responsible: ED, MD, and or Designee Due Date: 07/01/2022
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation and staff interviewed, the findings of the most recent inspection of the facility was not posted in the facility. Evidence: 1. On 6-30-22, staff #8 was asked where the recent inspection was posted as it was not on the bulletin board with other posted documents. Staff stated in was in the binder. Staff went to a closet in the area where the concierge is and retrieved a binder which contained the facility?s inspection. Upon opening the binder, the most recent inspection was dated 4-22-20. 2. On 6-30-22, staff #1 and #8 acknowledged the most current inspection was not posted and not in an area available for the public.
Plan of Correction:	What Has Been Done to Correct? Inspection Binder will always remain accessible at the front desk. How Will Recurrence Be Prevented? n/a Person Responsible:ED, AED, and or Designee Due Date: 07/01/2022