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: Feb. 13, 2023 , Feb. 14, 2023 and Feb. 27, 2023

Complaint Related: No

Areas Reviewed:

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal On-site renewal inspection conducted two days, 2-13-23 (Ar 07:55 a.m. /dep 4:55 p.m.), 2-14-23 (ar 9:30 a.m./ dep 2:30 p/m) The facility census on 2-13-23 was 70, a tour of the facility was conducted, medication pass observation, activity, emergency preparedness/ first aid kit check, resident and staff records and interviews conducted. A preliminary exit conducted with the administrator and staff on 2-13-23 and 2-14-23. The Acknowledgement of Inspection form was signed and dated on both days by the Administrator. 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. 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 #:	22VAC40-73-1140-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure within four months of starting dated of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairment. Evidence: 1. On 2-14-23, staff #2?s training record documented 9 hours of the required cognitive training within four months of hire. Staff?s date of hire documented as 7-26-22. 2. Staff #1 and #10 acknowledged the aforementioned staff record did not document the required number of cognitive training hours within four months of hire.
Plan of Correction:	What Has Been Done to Correct? Staff member has completed the 1 hour of training that was required How Will Recurrence Be Prevented? Quarterly, the ED/designee will complete a review of direct care staff training records to assure that at least 10 hours of training in cognitive impairment has been completed for new direct care staff hired during that quarter. If training is not complete, the direct care staff person will not be allowed to work in the safe, secure environment until proof of completion. Person Responsible: ED or designee
Standard #:	22VAC40-73-220-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that the requirements of 22VAC40-73-250-D.1 through D.4 regarding tuberculosis (TB) are applied to private duty personnel. Evidence: 1. On 2-14-23, a review of resident #8?s ISP noted, staff #6 documented on 12-19-22, resident?s home health aide (private duty sitter) services. A review of #12?s personnel record did not include documentation of the results of a current TB. 2. Staff #1 acknowledged the aforementioned resident?s private sitter?s record did not include the results of a current TB.
Plan of Correction:	What Has Been Done to Correct? How Will Recurrence Be Prevented? Community will maintain an up to date listing of residents with pvt duty aides. Prior to private duty aide/sitter starting with resident, the BOM/designee will obtain or will receive proof that the agency is able to provide, if requested, appropriate paperwork and documentation as per regulatory standard, to include TB screening results. For the next 60 days, the ED/designee will audit new pvt duty personnel?s paperwork to assure appropriate paperwork and documentation is available per regulatory standard Person Responsible: BOM or designee
Standard #:	22VAC40-73-260-C
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the listing of all staff who are current in first aid or CPR or both was kept up to date and staff maintain current certification per 22VAC40-73-260. Evidence: 1. On 2-13-23, the facility?s first aid and CPR posted in the safe, secure unit and the assisted living nursing area noted the document was ?updated 10-20-22?. The following were on the list with expired first aid/CPR dates and listed on the work schedule for the week of 2-12-23 to 2-18-23: (a) staff #2, FA/CPR expired 1-3-23, (b) staff #15, FA/CPR expired 12-21-22, (c) staff #17, FA/CPR expired 1-31-23. 2. Staff #14?s FA/CPR expired 1-1-22. 3. Staff #1, #2 and #3 and #7 acknowledged the first aid/CPR posted listings were not kept up to date and staff did not maintain required first aid training.
Plan of Correction:	What Has Been Done to Correct? Current community staff have attended CPR class and are up to date. How Will Recurrence Be Prevented? The BOM designee will maintain an up to date listing of all staff who are current in first aid, CPR, or both and will monitor the expiration dates of CPR and First Aid certification for current staff to ensure that documentation of CPR and First Aid training is kept up to date and in the employees? files. CPR/First Aid training will be provided on-site at regular intervals to assure compliance. Person Responsible: BOM or designee
Standard #:	22VAC40-73-310-H
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 one of eight residents. Evidence: 1. On 2-14-23, resident #2?s February 2023?s physician order sheet (pos) documented Xanax prescribed 11-15-22. The record did not include a psychotropic treatment plan. 2. Staff #6 acknowledged the aforementioned resident?s record did not have a psychotropic treatment plan for Xanax.
Plan of Correction:	What Has Been Done to Correct? Psychotropic medication has been discontinued due to non-usage. How Will Recurrence Be Prevented? Psychotropic Treatment Plans will be obtained for current and new residents that are receiving psychotropic medications. RCD/designee will assure PTPs are obtained at admission and with the addition of new or changed dosages of psychotropic medications. RCD/designee will review Psychotropic Treatment Plans at least every 6 months, and as needed, to assure they include current psychotropic meds as ordered. Person Responsible: RCD or designee
Standard #:	22VAC40-73-350-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ascertain prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential will have a length of stay greater than three days or in fact stays longer than three days and shall document in the record in the resident?s record that this was ascertained and the date the information was obtained. Evidence: 1. On 2-14-23, resident #6?s sex offender document in the record was dated 1-6-23. The resident?s date of admission was documented as 12-19-22. 2. Staff #1 acknowledged the aforementioned resident?s sex offender was not conducted prior to admission.
Plan of Correction:	What Has Been Done to Correct? Sex offender report had been obtained prior to licensure renewal. How Will Recurrence Be Prevented? BOM/designee will complete the sex offender search and provide findings to the ED/designee for review prior to admission. For the next 60 days, after each admission, the ED/designee will complete an audit of the resident record to assure sex offender search findings is available in the resident file. Person Responsible: BOM/designee and ED/designee
Standard #:	22VAC40-73-380-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s personal and social information placed in resident?s record was kept current for one of eight residents. Evidence: 1. On 2-13-23, resident #3?s admitting physical examination dated 1-17-23 documented resident?s allergy to Ciprofloxacin. This information was not documented on the resident?s personal and social data form, residents date of admit noted as 1-30-23. 2. Staff #1 acknowledged the aforementioned residents? personal and social data document were not updated as required.
Plan of Correction:	What Has Been Done to Correct? Personal and social data form was updated. How Will Recurrence Be Prevented? RCD or designee will review personal and social data forms upon admission and at least annually or as needed to ensure that information is current. For the next 30 days, the ED/designee will complete regular, random audits of resident?s personal and social information to assure it is completed as appropriate and up to date. Person Responsible: RCD or designee
Standard #:	22VAC40-73-390-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it obtain at or prior to admission, a written agreement/acknowledgement of notification dated and signed by the resident or applicant for admission or appropriated legal representative, and by the licensee or administrator. Evidence: 1. On 2-13-23, resident #4?s record did not include a signed agreement for the extended respite stay services (12-29-22 to 1-31-23). The record also did not have signed and dated resident agreement for the change from respite stay to admission stay beginning 2-1-23. 2. Staff #1 acknowledged the facility did not have signed resident agreement for the resident?s respite and change to long-term admission stay in the facility.
Plan of Correction:	What Has Been Done to Correct? Appropriate agreements have been signed now that resident is now permanent resident of community. How Will Recurrence Be Prevented? The ED/designee is responsible for assuring that resident agreements are signed when appropriate. Should a resident wish to extend their respite stay or become permanent resident of community, the ED/designee will assure that appropriate documents are signed by the resident/responsible party and the ED. Person Responsible: ED or designee
Standard #:	22VAC40-73-410-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure upon admission, the facility shall provide an orientation for new residents and their legal representative?such documentation shall be kept in the resident?s record. Evidence: 1. On 2-14-23, resident 6?s record did not have signed and dated documentation of the resident and their legal representative?s orientation to the facility. The resident?s date of admission noted as 12-19-22. 2. Staff #1 acknowledged documentation of orientation to the facility was not in the resident?s record.
Plan of Correction:	What Has Been Done to Correct? Audit will be completed of each resident?s file to assure there is documentation of orientation is available. How Will Recurrence Be Prevented? ED/designee will provide orientation for new residents and their legal representative prior to or day of residents admission. Documentation of orientation will be maintained in the resident file. Over the next 60 days, the BOM/designee will complete an audit of new admissions to assure resident orientation has been completed. Person Responsible: ED/RCD or designee
Standard #:	22VAC40-73-440-K
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure for private pay individuals, the uniformed assessment instrument (UAI) shall be completed as required for one of eight records reviewed. Evidence: 1. On 2-14-23, resident #4?s uniformed assessment instrument (UAI) dated 1-10-23 was not signed and dated by an assessor or reviewer if the assessor was an employee of the facility. 2. Staff #1 acknowledged the aforementioned UAI was not completed as required.
Plan of Correction:	What Has Been Done to Correct? UAI has been signed by assessor and reviewer. How Will Recurrence Be Prevented? The UAI will be completed by an appropriately trained individual to address the needs of the resident as per regulatory standards. The assessor will sign the UAI, and the UAI will be provided to the ED/designee for review and signature. Over the next 60 days, the ED/designee will complete an audit of current and new resident charts to assure UAI is complete and has been signed as appropriate. Person Responsible: ED/RCD or designee
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessment needs for seven of eight residents. Evidence: 1. On 2-13-22, resident #1?s individualized service plan dated 10-9-22, (completed by staff #19) documented resident?s code status as ?Full Code: CPR will be performed??. The resident?s record included a physician?s signed and dated Do Not Resuscitate (DNR) document dated 10-22-22. The record included documentation of psychological services provided on 5-13-22, 6-13-22, 7-25-22, 8-4-22, 10-20-22, 12-15-22 and 2-2-23. This service was not documented on the ISP. Evacuation need documented resident?s need for staff to use a gait belt for transfer and slide board. Staff #1 stated the resident does not need use of gait belt neither a slide board. 2. Resident #2?s ISP,(completed by staff #18) documented resident?? current or history of wandering...may wander outside facility?. The uniformed assessment instrument (UAI) dated 12-3-22, did not document wandering behavior. The resident?s February 2023 physician?s orders document dated 12-1-22 documented Sulfa Antibiotics and Macrobid allergy. This information not documented on the ISP dated 12-3-22. The resident?s ISP dated 12-3-22 documented resident?s code status as ?Full Code: CPR will be performed??. The resident?s record included a physician?s signed and dated Do Not Resuscitate (DNR) document dated 11-3-22. 3. Resident #4?s uniformed assessment instrument (UAI) dated 11-28-22 and 1-10-23 assessed transferring need as mechanical help/physical assistance (mh/pa), the ISP dated 11-28-22 and 1-10-23, (completed by staff #18) did not document a mechanical device. The record included a physician?s order dated 11-29-22 for bed rails for positioning for weakness. The bedrails are not documented on the ISP. 4. Resident #5?s ISP dated 10-10-22, (completed by staff #19) documented code status as ?DNR? and ?Full Code?. The record included a physician?s signed and dated DNR dated 10-8-21. The record included documentation of psychological services on 6-13-22, 7-18-22, 8-4-22, 9-6-22, 10-6-22, 11-17-22, 12-15-22, and 2-2-23. This service was not documented on the ISP. Evacuation need documented resident?s need for staff to use a gait belt for transfer and slide board. Staff #1 stated the resident does not need use of gait belt nor slide board. The UAI dated 10-7-22 documented stairclimbing need as mh/pa and mobility as mh. The ISP documented ?mobility/ambulation...may use handrails?may require prompts/cues for safety, does not require hands on assistance, walker?. Evacuation need documented resident?s need for staff to use a gait belt for transfer and slide board. Staff #1 stated the resident does not need use of gait belt nor slide board. Bathing need assessed as supervision. The ISP documented, ?verify bench is available and used during bathing?. Wheeling assessed as not performed, this need is not on the ISP. Wheeling assessed as not performed, this need is not on the ISP. The record included plan of care for physical therapy services (1-6-23 to 3-29-23), occupation therapy (1-6-23 to 3-29-23) and speech therapy (1-13-23 to 3-10-23). These services were not documented on the ISP. 5. Resident #6?s ISP dated 1-31-23, (completed by staff #6) did not include physical therapy (PT) services, admitting physical dated 11-15-22 document evaluation and treat. The record documented PT evaluation 2-2-23, and skilled nursing (SN) wound care to lower extremity from a local home health agency. These services were not on the ISP. Evacuation need documented resident? use of electric wheelchair, ?need help downstairs?. The ISP did not document what help to be provided. Resident resides on the second floor and has a physician?s order dated 12-22-22 documenting ?cannot ambulate? and UAI documented walking ?not performed? and ISP documented resident is ?mobility dependent?.
Plan of Correction:	What Has Been Done to Correct? ISP/UAI will be reviewed and changed to ensure missing items will be documented on both documents. 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 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
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 his designee, the person who has developed the plan, and the resident or the legal representative for three of eight records. Evidence: 1. On 2-13-23, resident #2?s individualized service plan (ISP) dated 12-3-22 and completed by staff #18, was not signed and dated by the resident or the legal representative. 2. On 2-13-23, resident #5?s ISP was updated to include resident?s change in condition, resident?s admission to hospice services dated 1-20-23. This update was not signed and dated by the resident or the legal representative. 3. On 2-14-23, resident #7?s ISP dated 11-27-22 and completed by staff #18, was not signed and dated by the resident or the legal representative. 4. Staff #1 acknowledged the aforementioned ISPs were not signed and dated by the resident or legal representative.
Plan of Correction:	What Has Been Done to Correct? ISPs have been signed by appropriate individuals as per regulatory standard How Will Recurrence Be Prevented? The RCD/designee is responsible for assuring that the ISP is appropriately reviewed and signed, upon completion, by the ED/designee, resident and/or responsible party. Over the next 30 days, the RCD/designee will complete an audit of current ISPs to assure they have been appropriately signed by individuals as required. Over the next 60 days, the ED/designee will complete a review of newly completed ISPs and/or updated ISPs to assure they have been signed by the appropriate individuals. Person Responsible: RCD or designee
Standard #:	22VAC40-73-580-A
Description:	Based on interview, the facility failed to ensure when any portion of the facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as evidenced by an initial and subsequent annual reports from the Virginia Department of Health. The report shall be retained at the facility for a period of at least two years. Evidence: 1. On 2-13-23, the ?What your inspector needs from you today? document was returned to the licensing inspector. The section requesting the ?most recent health department inspection? was blank. Interview with staff #1 revealed the facility did not have a recent health inspection. Documentation from the last renewal inspection noted a health inspection document dated June 2022. 2. Staff #1 acknowledged the facility did not have a current health inspection.
Plan of Correction:	What Has Been Done to Correct? Virginia Department of Health inspection was completed How Will Recurrence Be Prevented? The ED/designee will assure that the Virginia Dept of Health inspection is completed at least annually. If there is communication from the health department regarding a need to delay inspection, this communication will be maintained by the ED for review. Inspections will be maintained for review as per regulatory standard Person Responsible: ED or designee
Standard #:	22VAC40-73-640-D
Description:	Based on observation and staff interviewed, the facility failed to ensure the pharmacy reference book, drug guide, or medication handbook was no more than two years old as reference for staff who administer medications. Evidence: 1. On 2-13-23 during the medication pass observation with staff #2 on the facility?s safe, secure unit (Sweet Memories), the medication handbook was dated 2018. 2. Staff #2 acknowledged the medication book present on the cart was more than two years old.
Plan of Correction:	What Has Been Done to Correct? Drug Handbook 2023 was received from the pharmacy How Will Recurrence Be Prevented? Drug Handbook will be ordered from the pharmacy at least every 2 years to assure continued compliance Person Responsible: RCD or designee
Standard #:	22VAC40-73-860-G
Description:	Based on observation and staff interviewed, the facility failed to ensure the hot water at taps available to residents shall be maintained within a range of 105 degrees to 120 degrees Fahrenheit (F). Evidence: 1. On 2-13-23, the water temperature in room #121 on the safe, secure unit (Sweet Memories) conducted by staff #9 registered a temperature of 138.9 degrees F. 2. Staff #9 acknowledged the water temperature was out of the required range of 105 to 120 degrees F.
Plan of Correction:	What Has Been Done to Correct? Water temperature was corrected during survey How Will Recurrence Be Prevented? The Maintenance Director/designee will complete monthly checks of water temp to assure it is maintained between 105 and 120. For the next 30 days, the maintenance director/designee will complete weekly water temperature checks on each resident apartment and in common areas then provide to ED/designee for review. Concerns will be addressed immediately. Person Responsible: Maintenance Director or designee
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interviewed, the facility failed to ensure first aid kit available included all required items. Evidence: 1. The first aid kit on the van which transport residents was inspected with staff #8. The kit did not have extra batteries, the flashlight did not work and the antiseptic ointment was dated 11/2022. 2. All staff acknowledged the first aid kits did not contain all required items.
Plan of Correction:	What Has Been Done to Correct? First aid kits have been reviewed and restocked with appropriate required items. How Will Recurrence Be Prevented? First aid kits will be reviewed monthly to assure required items are in date, available and operable. The ED/designee will complete regular, random audits of the first aid kits to assure they remain in compliance. Person Responsible: ED/RCD or designee