VIRGINIA DEPARTMENT OF SOCIAL SERVICES

COMMONWEALTH SENIOR LIVING AT GLOUCESTER HOUSE
7657 Meredith Drive
Gloucester, VA 23061
(804) 693-3116

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: Sept. 9, 2022 and Sept. 12, 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 63.2 GENERAL PROVISIONS 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

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/09/2022 & 09/12/2022 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: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 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 Alyshia E. Walker, Licensing Inspector at (757)670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on observation and staff interview, the facility failed to ensure its blood glucose monitoring practices were consistent with CDC recommendations. Evidence: 1. On 09/09/2022, during the medication pass observations with Staff # 4, the inspector observed the staff member taking Resident # 6?s glucometer out of the case and placing the instrument on top of the medication cart. The area where the glucometer was placed was not sanitized prior to the glucometer being placed and the staff did not place a barrier between the medication cart top and the resident?s glucometer. Staff # 4 acknowledged not following infection control practices. 2. On 09/12/2022, during medication pass observation with Staff# 5, Resident #5?s glucometer was not labeled. Staff#5 acknowledged the glucometer was not labeled.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-B
Description:	Based on record review and staff interview, the facility failed to ensure a risk assessment for tuberculosis was completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. On 09/12/2022, Resident #2?s most recent TB assessment was dated 01/11/2021 and Resident#4?s most recent TB assessment was dated 11/06/2020.\ 2. Staff #1 acknowledged the aforementioned resident TB assessments were not completed as required.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-A
Description:	Based on record review and staff interview, the facility failed to ensure a reassessment using the uniform assessment instrument (UAI) was utilized to determine whether a resident?s need can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: 1. On 09/09/2022, Resident #2?s UAI was last dated 12/02/2021. The resident resides in the facility?s safe, secure unit and the UAI assessment is completed every six months. 2. Staff #1 acknowledged the aforementioned resident?s reassessment using the UAI was not completed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-A
Description:	Based on record review and staff interview, the facility failed to ensure a resident?s preliminary plan developed addressed the basic needs of the resident that adequately protect the health, safety, and welfare. Evidence: 1. On 09/09/2022, Resident # 1?s preliminary service plan dated 09/01/2022 did not include the resident?s need for Palliative Care. The resident?s admitting orders dated 08/31/2022 documented resident?s palliative medications and care need. 2. Resident #1?s uniform assessment instrument (UAI) dated 09/01/2022 noted toileting need as human help/supervision however the preliminary service plan did not document what type of assistance needed to be provided. 3. Resident #1?s UAI noted the resident was disoriented in some spheres (time/place) all the time. The preliminary ISP did not address how staff would provide redirection/reorientation to the resident. 4. Resident #1?s UAI assessed that when was not performed. The preliminary ISP did not address this need. 5. On 09/12/2022, Staff #1 acknowledged the resident?s palliative care need was not documented on the preliminary plan of care.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, document review and staff interview, the facility failed to ensure the individualized service plan (ISP) included all assessed needs. Evidence: 1. On 09/12/2022, Resident #4?s uniform assessment instrument (UAI) dated 03/23/2022 documented toileting need assessed as mechanical/physical assistance. The ISP dated 03/22/2022 did not include who would provide the services. Stairclimbing was assessed as not performed. The ISP for Resident #4 did not include this assessed need. Resident #4?s record included documentation the resident was provided physical therapy and occupational therapy services. These services were not documented on the resident?s ISP. Resident #4?s record also included a signed physician?s order for ? side rail for support getting out of bed and repositioning. This was not included on the ISP. 2. On 09/12/2022, Resident # 3?s UAI dated 03/23/2022 assessed dressing as human help/physical assistance. The ISP dated 03/22/2022 documented the resident needed mechanical help using the grab bar. The UAI assessed Resident#3 as needing mechanical help with eating. The ISP documented food to be cut up, containers opened and encouragement to eat. The ISP did not address the mechanical need. Resident #3?s record included documentation the resident received physical therapy. This service was not documented on the ISP as current, or outcome achieved. 3. On 09/12/2022, Resident # 5?s record included speech therapy service documentation (physician?s order dated 05/03/2022 and discharge on 06/03/2022). This service was not documented on the resident?s ISPs dated 04/03/2022 and 05/03/2022. Resident #5?s record included documentation the resident received skilled nursing services for wound care (physician order dated 05/03/2022). This service was not documented on the preliminary or comprehensive ISPs dated 04/03/2022 and 05/03/2022. Resident #5?s record also included documentation the resident received physical therapy services. These services were not documented on the ISP. 4. On 09/12/2022, Staff #1 acknowledged the aforementioned residents? ISPs did not include all assessed needs.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on resident records review and staff interview, the facility failed to ensure the individualized service plans (ISP) updated as needed for a significant change of a resident?s condition. Evidence: 1. On 09/12/2022, Resident # 2?s ISP end date/review dated was documented a 06/02/2022. The resident resides on the facility?s safe, secure unit and the ISPs are reassessed every six months. 2. On 09/12/2022, Resident #5?s ISP end/review date was documented as 07/22/2022. 3. Staff #1 acknowledged the aforementioned residents? ISPs were not updated as required.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-M
Description:	Based on record reviewed, observation and staff interviewed, the facility failed to ensure medications ordered for PRN administration was available, properly labeled for the specific resident and properly stored at the facility. Evidence: 1. On 09/12/2022, during medication pass observation with Staff #5, Resident # 4?s PRN Anecream was not available in the facility. The physician?s orders dated 09/12/2022 included the PRN Anecream medication.
Plan of Correction:	Not available online. Contact Inspector for more information.