VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Kilmarnock
460 S. Main Street
Kilmarnock, VA 22482
(804) 435-9896

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: June 7, 2023

Complaint Related: Yes

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: On 06/07/2023- the approximate times of 11:09a.m-12:39p.m 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 01/05/2023 regarding allegations in the area of resident care. Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: 3 Observations by licensing inspector: No concerns noted Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law. 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-460-D
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that the facility provided supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls. Evidence: Resident #1 Documented date of admission 10/31/2016 Documented date of discharge: 02/20/2023 The facility?s nurses? progress notes documents and physician?s orders charting for November and December 2022 and interviews conducted with facility staff and the resident?s power of attorney revealed the following: 09/17/2022: The residents? Uniform Assessment Instrument (UAI) notes ?Yes? under the heading Transferring; indicating that this task is performed by others. Under the heading Walking facility staff noted that the resident did not need assistance with this task; indicating that this function is not performed. 09/27/2022: The resident?s Individualized Service Plan (ISP) revealed a handwritten entry noting ? ? side rails for turning, positioning and safety. Staff to ensure ? siderails are used while (resident identified) is in bed.? 10/13/2022: Using the Morse Fall Scale the facility assessed the resident as being a high fall risk; with a score of 80 points. 12/09/2022: Resident #1 fell out of his bed sustaining injuries that required outside emergency medical intervention. Later, on12/09/2022 after the resident?s fall- the facility received a physician?s order for ?? side rails, lowest position, fall mat.? Upon request the facility did not submit for the inspector?s review documented evidence that a physician?s order had been obtained regarding the bedrails noted on the 09/27/2022 care plan or that a plan of care had been implemented to reduce continued falls.
Plan of Correction:	FACILITY'S RESPONSE: "Resident no longer resides in the community. Audit will be completed of current residents ISP to ensure current needs are appropriately documented to include fall risk interventions. The audit will be completed by 08/31/2023. Training has been provided to RCD on reviewing and updating interventions to the ISP when needed. Training was completed 07/20/2023. Moving forward, the Resident Care Director or designee will assure appropriate needs and interventions are documented/updated to the residents ISP, at move in, at 30-day, annually and change of condition; and, if needed, will assure that physician's orders are in place to match the intervention. For the next 60 days, beginning 7/21/2023 the ED will review new and current ISPs updated during that week, to ensure interventions are appropriate to current needs."