VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Williamsburg
236 Commons Way
Williamsburg, VA 23185
(757) 564-4433

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Dec. 5, 2022 , Dec. 9, 2022 and Dec. 15, 2022

Complaint Related: No

Areas Reviewed:

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Monitoring On 12-05-22 an on-site IPOC monitoring inspection was conducted (ar 08:55/dep 18:25). Day 2 on-site was conducted on 12-9-22 (ar 09:20/dep 13:00). The facility census on 12-05-22 was 59. Four resident records were selected from the sample, a medication pass was observed and staff interviews were conducted. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757-439-6815) or by email at willie.banres@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1110-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure six months after placement of the resident in the safe, secure environment, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident?s continued residence in the special care unit. Evidence: 1. On 12-5-22, resident #3?s record did not include a six-month continued need for placement in the special care unit. The resident?s date of admit to the safe, secure unit was dated 2-11-22. 2. Staff #1 acknowledged the resident?s six-month assessment for continued placement in the special care unit was not in the record.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit and or retain residents with any of the prohibitive care needs and or conditions with proper documentation in accordance with 63.2-1805 D Code of Virginia for two of four residents. Evidence: 1. On 12-5-22 resident #3?s record included a phone order dated 9-20-22 for Lorazepam. The record also documented Seroquel and Trazadone use. The record did not include a treatment plan for these psychotropic medications. 2. Resident #4?s record documented physician?s order dated 3-10-22 for Seroquel. The record did not include a treatment plan. 3. Staff #1 acknowledged the residents? record did not include a treatment plan for psychotropic medication as required.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-380-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s personal and social data form was kept updated for four of four resident?s records. Evidence: 1. On 12-5-22, resident #1?s social data date of admission, dentist and the address sections were blank. 2. Resident 2?s social data dentist section was blank. 3. Resident #3?s social data address, birthplace, allergy, advance directive, service in armed forces and advance directives sections were blank. 4. Resident #4?s social data dentist and service in armed forces were blank. The allergy section did not include all allergies. The physical examination dated 3-3-21 and the facility?s ?Notification of Allergy? form documented Cephalexin and Sulfa. 5. On 12-5-22, staff #1 and #2 acknowledged the residents? personal and social data form was not updated.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-K
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the uniformed assessment instrument (UAI) form was completed as required for one of four residents. Evidence: 1. On 12-5-22, resident #3?s UAI dated 9-30-22 did not include the second signature of administrator or designee when UAI is completed by a facility staff. 2. Staff #1 acknowledged the resident?s UAI was not signed as required.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the preliminary plan was signed and dated by the licensee, administrator, or designee and by the resident or the legal representative. Evidence: 1. On 12-5-22, resident #2?s preliminary plan of care did not include the signatures of the resident/ legal representative or the facility staff. 2. Staff #2 acknowledged the resident?s preliminary plan of care was not signed and dated as required per the regulation.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based on observation, record reviewed and interviews, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for four of four residents. Evidence: 1. On 12-5-22, resident #1?s record included a physician order dated 4-4-22 for PRN oxygen, 2 Liter via nasal cannula and resident receives sitter services according to sitter contract and interviews with staff #2 and #3. The uniformed assessment instrument (UAI) dated 7-29-22 assessed bathing need as human help/physical assistance, the ISP documented help help/physical assistance and use of a shower bench. Mobility assessed as mechanical help/human help-supervision. The ISP documented resident requires hands on assistance by staff during ambulation and transfers. 2. Resident #2?s ISP dated 12-1-22 documented in the demographics- DNR/CPR will be withheld. The resident?s social date documented resident is a Full Code. The record did not include a signed and dated physician Do Not Resuscitate document. The UAI dated 11-28-22 documented bathing assessed as human help/physical assistance, the ISP documented shower bench and cueing needed during bathing. Dressing assessed as mechanical help/human help/physical assistance, the ISP did not document a mechanical device. The UAI documented no behaviors, the ISP documented resident is resistive to care. According to staff #2, resident will refuse activities of daily living care. Mobility assessed as mechanical help only, the ISP documented resident required hands on assistance for mobility/ambulation. Transferring assessed as mechanical help only, the ISP documented verbal cues- assistance with transfer and positioning. 3. Resident #3?s UAI dated 9-30-22 assessed transferring need as human help/supervision. The ISP documented resident require hands on for transfer or change in position. Stairclimbing assessed as not performed, this need was not documented on the ISP. Physical therapy service dates were documented in the record, evaluation and treatment dated 2-24-22. Psychiatric evaluation and treatment document in record, 6-8-22, 6-23-22 and 11-17-22 document notes in record. These support services were not documented on the ISP. 4. Resident #4?s UAI dated 6-25-22 bathing assessed as mechanical help only; the ISP dated 11-8-22 documented resident required supervision. Transferring assessed as mechanical help only, the ISP documented verbal prompts. Wheeling assessed as not performed, this need was not documented on the ISP. Resident?s record documented speech therapy services from 6-2-22 to 11-4-22. The record did not document this support service. The resident?s record also documented physical therapy services for balance, notes in the record dated from 5-4-21 to 5-26-21. This support service was not documented on the current ISP neither the previous ISP dated 5-11-21. 5. Staff #1 acknowledged the residents? ISP did not address all required needs.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or designee and by the resident or legal representative for one of four residents. Evidence: 1. On 12-5-22, resident #3?s individualized service plan (ISP) dated 10-7-22 was not signed and dated by the resident and/or legal representative. 2. Staff #1 acknowledged the resident?s ISP was not signed and dated.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, record reviewed, and staff interviewed, the facility failed to ensure prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: 1. On 12-5-22 during medication pass observation with staff #3, resident #1?s Miralax was not available to administer. A check of the communication log and resident?s progress notes were made to determine if medication was ordered on previous shifts. The medication was not ordered and not available for administration on the morning of 12-5-22. 2. Staff #3 acknowledged the medication was not available to administer to resident on 12-5-22.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-700-2
Description:	Based on observation and staff interviewed, the facility failed to ensure it post ?No Smoking- Oxygen in Use: signs on the doors where oxygen was in use. Evidence: 1. On 12-5-22 during the medication pass observation, oxygen equipment was observed in resident #1?s room. Upon exiting there was no oxygen sign observed on resident #1?s door. A review of the list of residents with oxygen revealed there were oxygen equipment in resident #5 and #6?s room. There was no oxygen sign on these doors. 2. Staff #2 acknowledged there were no ?No Smoking? signs posted on room doors of residents? #1, #5 and #6 on 12-5-22.
Plan of Correction:	Not available online. Contact Inspector for more information.