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: June 13, 2023 and June 14, 2023

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

Technical Assistance:

22VAC40-73-290 22VAC40-73-1140

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: 06/13/2023 from 8:40 am to 3:30 pm and 06/14/2023 from 9:33 am and 11:30 am. 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: 62 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: 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure the admitting physical examination include a completed risk assessment documenting the absence of tuberculosis in a communicable form 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. The initial TB risk assessment for Resident #3 (dated 5/2/23) and Resident #4 (dated 12/7/22) are not completed as they do not indicate a review of the risks or recommendation on if TB testing is indicated at this time.
Plan of Correction:	Resident #3 and #4 TB risk assessment was completed by their PCP. Re-educated Executive Director and Resident Care Director on regulation 73-320-A. Moving forward, TB risk assessment will be completed by the PCP and reviewed by the ED/RCD prior to admission.
Standard #:	22VAC40-73-490-A
Description:	Based on interview, the facility failed to retain a licensed health care professional who has at least two years of experience as a health care professional in an adult residential facility, adult day care center, acute care facility, nursing home, or licensed home care or hospice organization, either by direct employment or on a contractual basis, to provide on-site health care oversight. Evidence: 1. Staff #5 was unable to provide a copy of a completed Health Care Oversight.
Plan of Correction:	HealthCare Oversight completed on 6/28/2023. Re-educated Executive Director, Resident Care Director on regulation 73-490-A.
Standard #:	22VAC40-73-560-E
Description:	Based on observation, the facility failed to ensure all resident records be kept in a locked area. Evidence: 1. During the tour of the facility, the narcotic count book which includes confidential resident information for the first-floor medication cart in the assisted living was unattended and accessible as it was noted on top of the medication cart.
Plan of Correction:	Narcotic count book was moved to the locked cabinet behind the nurse station. Re-educated Executive Director, Resident Care Director, LPN, Wellness Secretary and RMAs on regulation 73-560-E. Narcotic count book to be stored in locked cabinet behind the nurse station on each floor.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication. Evidence: 1. The following expired medications were observed in the medication carts at the facility: Pravastatin 20mg tabs expired 01/31/2023 for Resident #4, Senna Plus 8.6-50mg tabs expired 05/09/2023 and Bisacodyl 5mg tabs expired 05/10/2023 for Resident #7, Stool Softener tabs expired 05/04/2023 for Resident #9, and Amlodipine Besylate 5mg tabs expired 06/06/2023 and Montelukast Sod 10mg tabs expired 05/02/2023 for Resident #10.
Plan of Correction:	Resident #4, #7, #9 and #10 expired medications were removed from the med cart. Re-educated Executive Director, Resident Care Director, LPN, Wellness Secretary, and RMAs on regulation 73-640-A. Med cart audits will be performed each week.
Standard #:	22VAC40-73-720-A
Description:	Based on record review, the facility failed to ensure a valid written Do Not Resuscitate (DNR) order has been issued by the resident's attending physician; and that the written order is included in the individualized service plan. Evidence: 1. Upon review of Resident #3?s record, their ISP (dated 5/17/23) and their personal data sheet indicate the resident as a DNR; however, the resident does not have a signed DNR order or Durable DNR in their record. 2. Upon review of Resident #6?s record, their ISP (dated 3/2/23) and their personal data sheet indicate the resident as a DNR; however, the resident does not have a signed DNR order or Durable DNR in their record.
Plan of Correction:	Resident #3 and #6 changed to Full Code until DNR is received. Audited remaining resident files to ensure compliance. Re-educated Executive Director, Resident Care Director, LPN, and Wellness Secretary on regulation 73-720-A. Completed DNR form will be collected prior to admission if applicable.
Standard #:	22VAC40-73-980-C
Description:	Based on record review and interview, the facility failed to ensure first aid kits be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence: 1. Two first aid kits within the facility were reviewed. The first aid kit on the first floor of the assisted living was last checked on 12/05/2022. The first aid kit on the second floor of the assisted living was last checked on 02/05/2023. 2. Staff #5 confirmed the first aid kits have not been checked monthly.
Plan of Correction:	Audit was performed on both First Aid kits. Re-educated Executive Director, Resident Care Director, and Wellness Secretary on regulation 73-980-C. First Aid kit audit will be performed every month and documented.
Standard #:	22VAC40-73-980-H
Description:	Based on observation, the facility failed to ensure the availability of a 96-hour supply of emergency drinking water with at least 48 hours of the supply on site. Evidence: 1. The emergency food and water supply reviewed with Staff #8 included several jugs of water with the expiration date of 7/2022 and 9/2022. The availability of unexpired water in the emergency supply is not enough to serve 62 residents for 48 or 96 hours in the case of an emergency.
Plan of Correction:	Emergency water supply delivered 6/28/2023. Re-educated Executive Director and Dining Service Director on regulation 73-980-H. Water bottles were dated 6/2023 and calendared for replacement in 2 years
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. There were not completed criminal history record reports for Staff #6 (hired 05/02/2023) and Staff #7 (hired 11/07/2022) in their record.
Plan of Correction:	Associates #6 and #7 removed from the schedule on until background checks are received and reviewed. Re-educated Executive Director and Business Office Manager on regulation 90-(BC3)-40-B. An audit of current associate files was performed to ensure compliance with regulations. Moving forward, new hires will not start until background check is received and reviewed.