VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living At Charlottesville
1550 Pantops Mountain Place
Charlottesville, VA 22911
(434) 977-4094

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: Sept. 9, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS XX 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS XX 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

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9-09-2022, 9:59 a.m - noon 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 7-22-2022 regarding allegations in the area of Resident Care and Related Services. 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 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-40-A
Description:	Based on record review and interview, the facility failed to ensure the licensee ensured compliance with the facility's own policies regarding staff conducting rounds on the memory care unit. Evidence: 1. The facility?s policy, ?CL27 ? Resident Two Hour Round Check (07/02/2020)? documented, ?All residents residing in the Sweet Memory Neighborhood shall be checked on every 2 hours using the Two-Hour Round Check Log. The Caregiver should physically see each resident?? 2. A self-reported incident was received on 7-19-2022 regarding a non-hospice death of a resident reported by Staff #3. A subsequent report was received on 7-21-2022 by Staff #4 regarding a disgruntled employee who was suspended (then terminated) for falsification of documentation. It was learned it was on the shift where the resident passed away and round logs were falsified regarding checking on Resident #1. 3. Physician?s Visit notes on 7-19-2022 documented, ?Per staff, patient [Resident #1] was found deceased in her chair this morning during AM [morning] rounds. Last seen at her baseline last night. No recent fall or changes in health noted. On exam at 0805 patient was sitting in her chair. No obvious trauma noted. No heart beat on auscultation, patient cold + in rigor. Estimated time of death midnight on 7-19-2022.? 4. Staff #3 confirmed that Staff #2 was working the 11 p.m. to 7:00 a.m. shift 7-18-2022 through 7-19-2022 where Resident #1 passed away at some point during the shift, and camera footage reviewed by Staff #3 documented Staff #2 not making rounds every two hours to check on the resident; however, Staff #2 documented on Two Hour Round Checks that Staff #2 made rounds four times (12 a.m., 2 a.m., 4 a.m., and 6 a.m.) to see Resident #1. 5. Staff #1 confirmed the facility?s policy was not followed by Staff #2.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-H
Description:	Based on record review and interview, the facility shall ensure that the care and services specified in the individualized service plan are provided to each resident. Evidence: 1. Resident #1 admitted 9-14-2018. Resident #1?s ISP dated 3-04-2022 documents the need for 2 hour rounding on the resident by direct care staff under ?Emergency and Evacuation? identified on 11-19-2021. 2. A final self-report on 7-22-2022 documented, ?Resident Care Associate entered resident?s [Resident #1?s] room at approximately 07:20AM to wake resident up for breakfast. Resident Care Associate noticed that resident was showing no signs of life. Resident was a DNR; therefore, no resuscitation efforts were attempted. House Physician, EMS and POA were notified.? 3. Staff #2 failed to provide the ISP services of 2 hour rounding as identified on Resident #1?s ISP due to Staff #2 not making rounds overnight on 7-18-2022 to 7-19-2022.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-460-B
Description:	Based on record review and interview, the facility failed to ensure care provision and service delivery included prompt response by staff to resident needs as reasonable to the circumstances. Evidence: 1. Resident #1?s ISP dated 3-04-2022 documented ?[Resident #1] unable to use the emergency response system. Direct care staff assist with 2 hour rounding to meet any unmet needs.? 2. A self-reported incident was received by Staff #3 regarding a resident passing on 7-19-2022 (non-hospice death). Resident #1 passed away on 7-19-2022 per a Physician?s Visit note documented in the resident?s record. This licensing inspector interviewed Staff #1 (onsite on 9-09-2022) and Staff #3 (via email on 7-21-2022). The interview with Staff #1 confirmed based on video evidence reviewed that Resident #1 was last seen in their apartment at approximately 9:16 p.m. on 7-18-2022. Staff #1 stated the resident at 4 p.m. on 7-18-2022 reported to direct care staff, ?Not feeling great?. Staff #1 stated that Resident #1 was not seen from approximately 9:16 p.m. to 7:20 a.m. the next morning during staff rounds where the resident was discovered deceased. Staff #3 in email stated, ??It was then discovered that Staff #2 had signed off on doing 2 hour checks for residents in our memory care when in fact, camera footage proved otherwise.? Staff #1 and Staff #3 confirmed that Staff #2 was assigned to check on Resident #1 during the overnight shift from 11 p.m. to 7:00 a.m. and failed to make rounds despite having signed round logs.
Plan of Correction:	Not available online. Contact Inspector for more information.