VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Kilmarnock
460 S. Main Street
Kilmarnock, VA 22482
(804) 435-9896

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

Inspection Date: Sept. 26, 2022

Complaint Related: No

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/26/2022 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: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication administration pass conducted Additional Comments/Discussion: 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-A
Description:	Based on observation the assisted living facility failed to implement an infection control program addressing the surveillance, prevention, and control of disease and infection that is consistent with the federal Centers for Disease Control and Prevention (CDC) guidelines and the federal Occupational Safety and Health Administration (OSHA) bloodborne pathogens regulations. Evidence: During observation of the 09/26/2022 afternoon medication administration pass facility staff #5 opened bottle of the medication Lorazepam, placed the medication in her hand, the medication was then emptied into cup from her hand and given to resident.
Plan of Correction:	FACILITY'S RESPONSE: "The Medication Aide was given a Written Performance and Counseling document that day and coached on the importance in following the Commonwealth Senior Living Infection Control Policies & Protocols. The Resident Care Director (RCD) and Nursing Designee(s) have met with each Staff Member on the importance of following this procedure. Subsequent In-services will be conducted monthly with all Nurisng Staff."
Standard #:	22VAC40-73-210-B
Description:	FACILITY'S RESPONSE: "Based on the review of facility records and interview conducted with facility staff the facility failed to ensure that all direct care staff attended at least 18 hours of training annually. Evidence: Facility staff training records that was submitted for the inspectors ?revealed the following: Staff #3: Documented date of hire 04/02/2020 - Working with Families on 4/12/21- 50 mins - Wandering and Elopement on 6/18/20 - 50 mins Staff #4: Documented date off hire 12/10/2019 - The Art of Caregiving on 9/7/20- 2 hrs - Dementia and Alzheimers on 9/7/20 - 4 hrs"
Plan of Correction:	FACILITY'S RESPONSE: "Both employees were Counseled on not completing their respective annual training hours and have begun so immediately. Expected completion is November 18, 2022. Going forward the Business Office Manager (BOM) and/ or Designee will complete all requiring new hire trainings with the first 30 days as required and will monitor and follow up on Yearly training required hours as well to ensure compliance."
Standard #:	22VAC40-73-325-B
Description:	Based on the review of facility records and interview conducted with facility staff the facility failed to ensure that annual fall risk ratings were conducted. Evidence: Resident #6: Documented date of admission 10/03/2016 Facility records that were submitted for the inspectors review was not documented to note that a fall an annual fall risk rating was conducted on the resident.
Plan of Correction:	FACILITY'S RESPONSE: "A Fall Risk assessment was completed for this resident on October 2, 2022 aligning with his anniversary month. Going forward the RCD and/ or Designee will ensure that the form is completed Yearly and "as needed" and updated in the records accordingly on an ongoing basis."
Standard #:	22VAC40-73-450-E
Description:	Based on the review of facility records and interview conducted with facility staff the facility failed to ensure that individualized service plans are signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: Resident #2-Documented date of admission 09/24/2022 The most recent ISP that was submitted for the inspector?s review is dated 03/03/2022. Resident #6: Documented date of admission 10/03/2016 The most recent ISP that was submitted for the inspector?s review is dated 03/18/2022. The ISP?s for resident #s 2 and 6 were not signed or dated by resident or resident's representative
Plan of Correction:	FACILITY'S RESPONSE: "The RCD and/ or Designee will set of a Date & Time to meet with and review ISP with the Responsible Party and/ or obtain Signatures. Going forward the RCD and/ or Designee will obtain the Resident and/ or Responsible Party signature on the ISP when it has been updated and/ or completed. Resident Charts to be Audited for this document by November 18th 2022 to ensure Compliance."
Standard #:	22VAC40-73-720-A
Description:	Based on the review of facility records and interview conducted with facility staff the facility failed to ensure that individualized service plans Evidence: Resident #2-Documented date of admission 09/24/2022 The resident?s most recent 03/03/2022 ISP that was submitted for the inspectors review notes " will receive cardiopulmonary resuscitation (CPR) in event of cardiac or respiratory arrest". The residents? DNR order is dated 06/27/2022.
Plan of Correction:	FACILITY'S RESPONSE: "The Residents ISP was immediately updated and documented to the Resident's CPR/DNR preference. The RCD and/or Designee reviewed all ISP's for accuracy and that was Completed by October 14, 2022."
Standard #:	22VAC40-73-925-B
Description:	Based on observation the facility failed to ensure that the common face/hand washing sinks had liquid soap for hand washing. Evidence: When engaged the inspector observed that the soap dispenser in the facility?s bathroom in the common hallway near the front office did not have soap for handwashing.
Plan of Correction:	FACILITY'S RESPONSE: "The Soap Dispenser was immediately refilled that day. The Maintenance Director and/ or Designee will monitor bathrooms several times weekly to ensure each dispenser has an adequately amount of soap or will replace if not. Completed on September 26, 2022 and monitored ongoing."