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: Jan. 19, 2023 , Feb. 13, 2023 and Feb. 27, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint An on-site joint APS complaint inspection was conducted on 1-19-23 (Ar 9:30 a.m./dep 2:05 p.m.). The facility census was 84. Staff and resident interviews were conducted. Resident records were reviewed and collateral interviews were conducted. A preliminary exit was conducted on 1-19-23, the administrator was not able to stay for the complete meeting. The Acknowledgement of Inspection form was signed and dated by the facility representative on 1-19-23. A complaint was received by VDSS Division of Licensing on 1-4-23 regarding allegations in the area of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 84 Number of resident records reviewed: 2 Number of staff records reviewed: Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 7 Observations by licensing inspector: yes Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at Willie. Barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-310-H
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure in accordance with 63.2-1805- D of the Code of Virginia, it did not admit or retain individuals with any of the prohibited conditions or care needs for a resident. Evidence: 1. Resident #1?s record included prescriber?s orders dated 12-22-22 for the following psychotropic medications: (a) Buspirone (original date 6-15-22), (b) Mirtazapine (original date 6-15-22), Paroxetine (original date 6-15-22) and Trazadone (6-15-22). The resident?s discharge summary from a local hospital also noted these psychotropic medications. 2. Staff #2 acknowledged resident #1?s record did not include a treatment plan for the aforementioned psychotropic medications.
Plan of Correction:	What Has Been Done to Correct? Psychotropic Treatment Plan was obtained for noted resident. How Will Recurrence Be Prevented? Psychotropic Treatment Plans will be obtained for residents that are currently receiving psychotropic medications. RCD/designee will assure PTPs are obtained at admission and with the addition of new or changed dosages of psychotropic medications. Person Responsible: RCD or designee
Standard #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessment needs for a resident. Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s individualized service plan (ISP) included all assessed needs. Evidence: 1. On 1-19-23 during a complaint inspection, resident #1?s uniform assessment instrument (UAI) dated 1-9-23, (completed by staff #2), documented transferring as mechanical help/physical assistance (mh/pa). The ISP documented, ?resident does not require assistance with transferring?. The UAI documented wandering/passive- less than weekly. The ISP did not address this assessed need. The ISP documented, ?resident has current or history of frequent disruptive, aggressive, or socially inappropriate behavior, either verbally or physically improper. The UAI did not assess the resident behavior pattern being abusive/aggressive/disruptive. The resident?s discharge summary from a local hospital dated 6-8-22 and 12-2-22 documented resident having a cardiac pacemaker. This was not documented on ISPs dated 1-9-23 nor 7-3-22. 2. On 1-19-23, during the complaint inspection regarding resident experiencing low oxygen saturation and needed to be changed but did not have clean diapers on 12-12-22, facility communication log noted resident was sent out to the hospital. The resident?s ISP dated 7-3-22, (completed by staff #3), did not include resident?s need for Oxygen. The record included prescriber?s orders dated 6-4-22 and 7-6-22 for ?O2 2L NC PRN SOB. However, the resident?s medication list did not include the need for oxygen. 3. CLI, was present in resident #1?s room conducting an evaluation following resident?s 12-1-22?s recent hospitalization for ?productive cough with yellow sputum production? per the discharge summary and observed resident experiencing low oxygen saturation. CLI requested facility staff to contact 911. Staff #5 and #6 confirmed being asked to contact 911 and resident?s need to go be sent out to the hospital on 12-12-22. Resident?s brief was heavily soiled, fecal matter present and had an odor, according to CLI. A facility staff was asked for an adult brief, but CLI was informed resident did have any and staff would need to borrow one. The resident?s ISP documented resident?s use of adult briefs. Resident returned to the facility with new order for dated 12-22-22 for O2 2L NC PRN SOB & O2 S 92%. 4. The discharge summary from the hospital dated June 2022 documented resident?s need for wound care to the sacrum and abdominal wound care related to peg tube removal. These needs were not documented on the ISP dated 7-3-22.
Plan of Correction:	What Has Been Done to Correct? ISP has been reviewed and updated to assure it matches the current UAI and additional service information has been added to address pacemaker, need for adult briefs, and oxygen usage. How Will Recurrence Be Prevented? The RCD/designee will assure that the assessed needs reflected on the ISP are accurate for new and current residents per regulatory standards. Over the next 60 days, the ED/designee will complete a thorough review of newly completed and/or updated ISPs to assure they accurately reflect that residents? current needs. Any updates or corrections that are needed will be addressed at time of review. Person Responsible: RCD or designee