VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Farnham
511 Cedar Grove Road
Farnham, VA 22460
(804) 394-2102

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: June 29, 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 ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Technical Assistance:

Technical assistance provided concerning addition security measure for the secure unit.

Comments:

Type of inspection: Monitoring- ( Other/Self Report ) Date(s) of inspection: and time: 5:45 p.m. to 6:01 p.m. the licensing inspector was on-site at the facility for each day of the inspection: 06/29/2022 and Time: 5:45 p.m. to 6:01 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 06/29/2022 regarding allegations in the area(s) of: 1) Safe, Secure Environment 2) Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 48 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 1 Observations by licensing inspector: The unit was fully staff and the exit door was secure. The facility may need to but a secure perimeter fence around the door as a secondary precaution measure. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 finding 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 Vashti Colson, Licensing Inspector at (804) 437-5205 or by email at Vashti.Colson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1150-A
Description:	VIOLATION: Based upon the record review, reports, and interviews, the facility failed to monitor all doors that leads to unprotected areas or through devices that conform to applicable building and fire codes, including door alarms, cameras , pressure pads at doorways, delayed egress mechanisms, constant staff oversight, locking devices, or perimeter fence gates. The facility failed to prohibit each resident in the secure environment from exiting the facility. EVIDENCE : Resident #1 was able to exit the secure unit on 05/31/2022 according to the hospital discharge , police report , and the facility?s incident report. It was noted in the hospital discharge that resident #1 wondered away from the facility?s secure unit and was found face down in the woods. According to a staff interview, resident #1 has exit seeking behaviors in which resident #1 will push on the secure exit doors while hitting the door. Staff confirmed that the secure unit?s alarm did not go off upon resident #1?s exit from the facility.
Plan of Correction:	What has been done or corrected: Doors to the facility were repaired on 06/01/2022 to ensure resident safety and the inability to exit the doors . How will recurrence be prevented : Alarms were also repaired at that time. Alarms and doors will be checked every 30 days to ensure all systems are working properly. Person Responsible: Executive Director and Maintenance Director.
Standard #:	22VAC40-73-450-E
Description:	VIOLATION : Based upon the record review, the facility failed to have the resident or the resident?s legal representative sign and date the individualized service plan. EVIDENCE: Resident #1?s March 09, 2022, Individualized Service Plan did not have the signature of the resident or the legal representative.
Plan of Correction:	What has been done to correct ? : This was during COVID. Resident's POA refused to come in at the time , but the ISP was emailed to her. She has since signed the care plan on. ( see attached date.) How will recurrence be prevented? : We will ensure that meetings will be scheduled on the date that the ISP are completed. We will email to those that are unable to come out at that time . Also , a note will be placed on the signature page with the date that it was emailed and it will be put in the medical charts until the signed copy is available. Person Responsible : Executive Director and Assistant Resident Care Director .