VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at South Boston
435 Hamilton Boulevard
South boston, VA 24592
(434) 575-5400

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date:

Complaint Related: No

Violations:

Standard #:	22VAC40-73-1040-A
Description:	Based on review of resident records, facility documentation and interviews with staff and family, the facility failed to ensure that their security system on doors leading to the outside properly monitored residents with cognitive impairments who cannot recognize danger or protect his own safety and welfare. EVIDENCE: 1. The record for resident 2, admitted to the facility on 06/28/2022, has a diagnosis of dementia as documented on the residents history and physical, which was not dated by the physician. 2. An assessment of serious cognitive impairment form signed by the physician on 06/17/2022 has documentation that resident 2 is unable to recognize danger or protect her own safety and welfare. Outside agency documentation dated 06/30/2022 has documentation that resident 2 has? intermittent confusion-ST to add goals for orientation, prob. Solving + memory. The individualized service plan (ISP) dated 08/07/2022 in the record for resident 2 has documentation under psychosocial that resident 2 has current or history of chronic hallucinations/delusions. 3. Documentation in progress notes dated 06/302022 at 10:27pm by staff 10 states the following ?Resident going into other residents rooms messing with their belongings. Tried going out the door behind her company?. Documentation in progress notes dated 07/06/2022 at 6:29pm by staff 10 states ?resident attempted to go out the door at the end of 200 hall?. Staff 3 documented in progress notes on 07/08/2022 at 4:55am ?resident attempted to go out the 200 hall exit door during the night. Resident was redirected to her room?. Documentation in progress notes dated 08/27/2022 at 10:28pm states ?staff 1 and I (staff 11) were in the middle of end of shift count when collateral witness 2 and resident 2 came in through front entrance. Collateral witness 2 stated that he found her a block over down Periwinkle Street. He stated that resident 2 had walked out the side door and walked across the street to Periwinkle Circle and went down another street in the circle and sat in a chair on the front porch of one of the homes. Collateral witness 2 stated that the owner had called the number that resident 2 had in her hand?. 4. The regional licensing office received a self-reported incident dated 08/28/2022 from staff 4 containing the following information regarding resident 2 ? Resident 2 and her POA presented to the community by front entrance. Her POA stated that he had been notified by a resident in an adjoining neighborhood that resident 2 was on their porch. He stated that resident 2 told him she had walked out the door at the end of the 20 hall of the community. She then sat in a chair on the porch of the residence. Resident was carrying her cell phone and asked the homeowner to call the POA as his number was on her cell phone?. 5. In an interview with staff person 1 conduced on 09/01/2022, it was expressed by staff person 1 that they were in the middle of change of shift report with staff person 11 on 08/27/2022 at approximatively 7:00pm when collateral witness 2 and resident 2 walked through the front door of the facility. Collateral witness 2 expressed to staff person 1 and 11 that resident 2 was over on Periwinkle Street when he received a call to come and get her. Staff person 1 stated that they had not heard any door alarms ringing, had never been told any door alarms were going off and that they were not aware that resident 2 had left the facility. 6. In an interview that was conducted with collateral witness 2 on 09/01/2022, it was expressed that he has noticed increased confusion with resident 2 during his visits with her over the past couple months prior to this incident. Collateral witness 2 also indicated that they were concerned about resident 2 having increased hallucinations. Collateral witness 2 explained that during their visits with resident 2, they noticed that resident 2 would have conversations with their husband and son, both of who are deceased. See attachment.
Plan of Correction:	In-service held for all associates to check all doors and surrounding areas outside of the doors that have been triggered by alarms, before clearing the alarm panel. All associates will be trained on how to respond to the alarm panel appropriately to ensure resident safety. RCD or designee
Standard #:	22VAC40-73-1130-A
Description:	Based on observation and staff interview, the facility failed to ensure at least three direct care staff were in the unit and on duty at all times. EVIDENCE: 1. During an on-site inspection conducted on 09/01/2022, the census in the facility?s safe, secure unit was 28 therefore requiring the facility to have at least three direct care staff in the unit and on duty at all times. At approximately 11:30AM, two licensing inspectors (LIs), observed that staff 1 and 2 were the only direct care staff on duty in the safe, secure unit. During an interview with staff 3 it was revealed that she was the third direct care staff on duty in the safe, secure unit; however, she was taking her break in the break room located in the facility?s assisted living section of the building. 2. Staff 3 stated that staff who are on duty in the safe, secure unit have to leave the safe, secure unit and go into the assisted living section of the building use the time clock to clock in and out for their lunch break due to there being no time clock in the safe, secure unit.
Plan of Correction:	Staff are to notify RCD or designee when they need to leave Memory Care for any reason to ensure the required number of staff are on duty at all times. Staff will be educated on staffing requirements in Memory Care. RCD or designee
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review, the facility failed to ensure that uniform assessment instruments (UAI) were completed as required. EVIDENCE: 1. The record for resident 2 has documentation in progress notes of the resident displaying wandering and exit seeking behaviors on several occasions. Progress notes dated 08/27/2022 in resident 2?s record also indicate that resident 2 eloped from the facility. Interviews with staff expressed that resident 2 has had an increase in confusion and has required redirection. The UAI dated 06/21/2022 in the record for resident 2 is inconsistent as it has resident 2?s behavior pattern as appropriate and that resident 2 is orient.
Plan of Correction:	The UAI will be updated to note resident?s behavior pattern for resident 2. RCD will be educated on updating UAI?s with changes in behavior pattern or orientation. All resident UAIs will be reviewed for compliance. RCD or designee.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure that identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The record for resident 2 has documentation in progress notes of the resident displaying wandering and exit seeking behaviors on several occasions. Progress notes dated 08/27/2022 in resident 2?s record also indicate that resident 2 eloped from the facility. Interviews with staff expressed that resident 2 has had an increase in confusion and has required redirection. The ISP dated 08/07/2022 in the record for resident 2 does not address these identified needs.
Plan of Correction:	The ISP will be updated to note resident #2 wandering and exit seeking behaviors. RCD will be educated on updating ISP to note behaviors. All resident ISPs will be reviewed for compliance. RCD or designee.
Standard #:	22VAC40-73-460-A
Description:	Based on resident record review, staff interviews and facility documentation review, the facility failed to assume general responsibility for the health, safety, and well-being of a resident. EVIDENCE: 1. Resident 1, admitted to the facility?s safe, secure unit on 04/05/2022, has a diagnosis of dementia as listed on a history and physical completed on 04/05/2022. The history and physical also has documentation that resident 1?s dementia can become agitated but can be redirected. 2. The private pay uniform assessment instrument (UAI) dated 07/20/2022 for resident 1 has documentation that the residents behavior pattern is abusive/aggressive/disruptive less than weekly and that resident 1 is also disoriented to all spheres all of the time. The individualized service plan (ISP) dated 05/13/2022 has documentation under neurocognitive that resident 1 has a current or history of frequent difficulty communicating and receiving information, cannot follow instructions, has difficulty in remembering and using information, has severe impairment, unable to remember or use information, may require repeated verbal prompts and/or direction. The ISP also has documentation under psychosocial that resident 1 may resist care often, needs protection and supervision because participant makes unsafe or inappropriate decisions. 3. Documentation in progress notes for resident 1 dated 07/01/2022 at 2:29pm written by staff 6 states the following: ?Resident does not remember to come inside from the heat when she gets too hot. Resident was observed trying to take off her shirt and was refusing to come back inside to cool off. I the writer and a RCA had to bring her back in so she could cool off. RCD (staff 5) made aware.? A progress note in the record for resident 1, dated 08/07/2022 at 2:38pm by staff 6, states the following: ?Resident was observed on the ground in the courtyard. Resident stated that she did not fall but she has a scrape and bruise starting on the right knee. Resident was extremely sweaty, cussing at staff and stating that she did not want our help. RCD (staff 5) made aware.? 4. The regional licensing office received a self-reported incident dated 08/28/2022 from staff 4 containing the following information regarding resident 1: ?08/27/2022 approximately 4:15PM ? Resident was observed outside in the memory care courtyard drooling from the mouth and nose. The resident was unable to completely respond to staff. She was brought inside. 911 called. The resident went to the ER. Resident suffered from heat exhaustion. She was transported to the ER and returned the same day.? According to timeanddate.com the temperature between 3:54PM and 4:54PM was 88 degrees Fahrenheit and sunny and the humidity was between 48% and 52%. An after visit summary from the hospital dated 08/27/2022 has documentation that resident 1 was diagnosed with heat exposure and information for heat exhaustion and heat disorders was attached to the summary. 5. A phone interview conducted with staff 7 on 09/02/2022 revealed that she was working on 08/27/2022 when the aforementioned incident occurred with resident 1. Staff 7 was informed by staff 8 that ?they needed help with resident 1 because the resident was outside in the courtyard, was disoriented, foaming at the mouth, somewhat responsive but was slow to speak?. Staff 7 stated that she called 911 around 3:30PM or 4:00PM and that the resident was ?wearing three layers of clothes if not more.? See attachment.
Plan of Correction:	Staff will be trained in documenting all interaction with residents in regards to their health, safety, and well-being. Staff will be trained to take into consideration the weather conditions before allowing a resident to spend time outside, to check on residents periodically and to redirect residents inside if needed. RCD/PD will hold in-service regarding documentation and the use of the memory care courtyard in certain weather conditions. RCD or designee