VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at King's Grant House
440 North Lynnhaven Road
Va. beach, VA 23452
(757) 431-8825

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: May 24, 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 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

Technical Assistance:

22VAC40-73-460 22VAC40-73-930

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/24/2023 from 8:30 am to 10:40 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 5/15/2023 regarding allegations in the area(s) of: Administration and Administrative Services, Resident Care and Related Services, and Buildings and Grounds. Number of resident records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were Administration and Administrative Services and Resident Care and Related Services. A violation notice was 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1090-A
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure prior to admission to a safe, secure environment, residents have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Resident #1 transferred into the safe, secure environment on 4/6/2023; however, the assessment of serious cognitive impairment was not completed until 4/29/2023.
Plan of Correction:	Re-educated Executive Director and Resident Care Director on regulation 73-1090-A. An audit will be completed of current resident?s residing in safe, secure environment to assure an assessment for serious cognitive impairment has been completed as per regulatory standards. This audit will be completed by 6/15/2023. Moving forward, prior to admission or within 7 days of admission, if emergency placement needed, to safe, secure environment the ED/designee will assure an assessment for serious cognitive has been completed by the physician.
Standard #:	22VAC40-73-1100-A
Complaint related:	No
Description:	Based on record review, the facility failed to obtain the written approval of one of the following persons listed in the standard of placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment. Evidence: 1. Resident #1 transferred into the safe, secure environment on 4/6/2023; however, Resident #1 did not have documentation of approval for placement in a special care unit in the resident?s record.
Plan of Correction:	Setting up meeting with resident #1 POA. Re-educated Executive Director, Resident Care Director, LPN, and Wellness Secretary on regulation 73-1110-A. An audit will be completed of current resident files to assure that written approval has been received for residents with a serious cognitive impairment currently residing in safe, secure environment. Audit will be completed by 6/15/2023. Moving forward, prior to placement in safe, secure environment due to serious cognitive impairment the ED/designee will assure that there is written approval for placement per regulatory standards.
Standard #:	22VAC40-73-1110-A
Complaint related:	No
Description:	Based on record review, the facility failed to ensure the licensee, administrator, or designee determine whether placement in the special care unit is appropriate for a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment. Evidence: 1. Resident #1 did not have documentation of the determination and justification on whether placement in the special care unit is appropriate by the licensee, administrator, or designee in their record.
Plan of Correction:	Setting up meeting with resident #1 POA. Re-educated Executive Director, Resident Care Director, LPN, and Wellness Secretary on regulation 73-1110-A. An audit of current resident files will assure that appropriateness for placement in a special care unit was reviewed prior to admission and that appropriateness of placement for continued residence has been completed at 6 months post admission and at least annually thereafter. Audit and updates, as warranted, will be completed by 6/15/2023. Moving forward, following regulatory standards, the ED/designee will review appropriateness of placement in special care unit prior to placement, 6 months post admission, and at least annually thereafter.
Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on record review and discussion, the facility failed to report to the regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. On 5/14/2023, Resident #1 was sent to the hospital for an abscess and returned later that same day. The After Visit Summary indicates Resident #1 reported allegations of abuse. 2. Through interviews with Staff #1 and Staff #2, it confirmed Resident #1 reported allegations of abuse while at the hospital. 3. There was no documentation of this allegation in Resident #1?s record nor was the allegation of abuse reported to the regional licensing office.
Plan of Correction:	Re-educated Executive Director and Resident Care Director on regulation 73-70-A. Moving forward, within 24 hours of major incidents that has negatively affected or that threatens the life, health, safety or welfare of any resident, the ED/designee will notify the regional licensing office as per regulatory standards.
Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on record review, the facility failed to ensure the UAI for residents be completed whenever there is a significant change in the resident's condition. Evidence: 1. Resident #1 transferred into the safe, secure environment on 4/6/2023; however, an UAI was not completed for this significant change. The last UAI for Resident #1 was completed on 9/9/2022.
Plan of Correction:	Updated resident #1 UAI to reflect change in condition. Re-educated Executive Director, Resident Care Director, LPN, and Wellness Secretary on regulation 73-440-A.
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on record review, the facility failed to ensure the individualized service plan be signed and dated by the licensee, administrator, or their designee, (i.e., the person who has developed the plan), and by the resident or their legal representative. Evidence: 1. Resident #1?s ISP dated 11/20/2022 is not signed and dated by the licensee, administrator, or their designee, (i.e., the person who has developed the plan), nor by the resident or their legal representative.
Plan of Correction:	Setting up ISP review meeting with resident #1 POA. Re-educated Executive Director, Resident Care Director, LPN, and Wellness Secretary on regulation 73-450-E. An audit will be completed of current residents? ISPs to assure that appropriate signatures have been obtained, per regulatory standards. This audit will be completed by 6/30/2023. Signatures that may be required will be obtained.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on record review, the facility failed to review and update individualized service plans as needed for a significant change of a resident?s condition. Evidence: 1. Resident #1 transferred into the safe, secure environment on 4/6/2023; however, Resident #1?s ISP was not reviewed or updated to reflect this significant change. The last ISP for Resident #1 was completed on 11/20/2022. The ISP completed 11/20/2022 also does not reflect the resident receiving home health services (effective 5/19/23) and the rounding frequency made by direct care staff to monitor for emergencies and other unanticipated resident needs.
Plan of Correction:	Resident #1 ISP updated to reflect Home Health Services and rounding every 2-hours by staff. Re-educated Executive Director, Resident Care Director, LPN, and Wellness Secretary on regulation 73-450-F.
Standard #:	22VAC40-73-470-F
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure when a resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional be secured immediately. The resident's physician, if not already involved, next of kin, legal representative, designated contact person, case manager, and any responsible social agency, as appropriate, shall be notified as soon as possible but no later than 24 hours from the situation and action taken, or if applicable, the resident's refusal of medical attention. A notation shall be made in the resident's record of such notice, including the date, time, caller, and person notified. Evidence: 1. Resident #1 was sent to the ER on 5/14/2023; however, there is no evidence or indication in the resident?s record that their legal representative was notified.
Plan of Correction:	Resident #1 POA was notified. Re-educated Executive Director, Resident Care Director, LPN, Registered Medication Aide, and Wellness Secretary on regulation 73-470-F.