VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at the West End
2400 Gaskins Road
Richmond, VA 23238
(804) 965-2155

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

Inspection Date: May 22, 2023 , May 25, 2023 and June 15, 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 ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS

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: 5-22-23 from 12:20 p.m.- 2:50 p.m., 5-25-23 from 9:30 a.m.-2:10 p.m., and 6-15-23 from 11:40 a.m.-1:50 p.m. 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: 82 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection: facility postings, facility documentation, lunch meal/menu, first aid kit, medication pass, physician?s orders, and medication administration records (MARs). An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-E
Description:	Based on a review of resident records the facility failed to ensure that the individualized service plan shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: The ISP (date of identified need: 4-24-23) for Resident # 4 (admit date: 3-31-23) was signed but not dated by the administrator designee or the resident. (Photographic evidence was taken.)
Plan of Correction:	All ISPs audited to ensure signatures and dates are in place in AL and SM Before filing ISP?s and UAI?s after care plan meeting. Ensure Executive Director, Resident Care Director, and designee sign and date ISP?s. ED and RCD will be responsible for this.
Standard #:	22VAC40-73-650-E
Description:	Based on a review of resident records the facility failed to ensure that the resident's record shall contain the physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's oral order. Orders shall be organized chronologically in the resident's record. Evidence: 3 of 5 resident records reviewed during the medication pass did not contain signed physician?s orders and staff were unable to locate them.
Plan of Correction:	All Resident files have been reviewed to ensure MD signatures are updated on all Resident orders. Medical Director reviewed forms on 6/20/23 reviewed and signed updated orders. Resident Care Director has set electronic reminders for Executive Director, and clinical department to ensure forms are signed semi annually. Forms signed will be scanned and kept electronically before filing in Residents chart. RCD and ED will be responsible for this.
Standard #:	22VAC40-73-720-A
Description:	Based on a review of resident records the facility failed to ensure that the resident?s Do Not Resuscitate (DNR) status is included in the resident?s individualized service plan (ISP). Evidence: The ISP (date of identified need: 1-15-23) for Resident # 3 (admit date: 7-2-19) did not address the resident?s DNR status, as it noted, ?DNR: CPR will be WITHHELD in the event of cardiac/respiratory arrest per Durable Do Not Resuscitate.? The ISP also noted, ?Full Code: CPR will be performed by certified staff in the event of cardiac/respiratory arrest.?
Plan of Correction:	All Resident charts pulled in Assisted Living and Memory Care to ensure this type of error is not being repeated on other Resident?s ISP?s. All ISP?s will be proof read before placing in chart and family signing, to ensure there are no duplicated code status and information correctly identified. Resident Care Director and Assistant Resident Care director will be responsible for this.
Standard #:	22VAC40-73-950-E
Description:	Based on a review of facility documentation the facility failed to ensure a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating. The orientation and review shall cover responsibilities for: 1. Alerting emergency personnel and sounding alarms; 2. Implementing evacuation, shelter in place, and relocation procedures; 3. Using, maintaining, and operating emergency equipment; 4. Accessing emergency medical information, equipment, and medications for residents; 5. Locating and shutting off utilities; and 6. Utilizing community support services. Evidence: The facility provided documentation of a review of the emergency preparedness and response plan that only contained the signatures of 6 staff members and no residents or volunteers.
Plan of Correction:	The Maintenance Director will review policy semiannually and conduct training with Residents, staff, and volunteer (where applicable). Electronic Calendar reminders will be sent out to each leader for 2 times a year training, 6 months apart. ED and Maintenance Director will be responsible for calendar reminders, that will give Community a chance to reschedule if needed.
Standard #:	22VAC40-73-970-A
Description:	Based on a review of facility documentation the facility failed to ensure that fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). Evidence: The facility failed to document a fire and emergency evacuation drill for the month of March 2023.
Plan of Correction:	Maintenance Director that started April 1 has put in place an electronic calendar reminder each month to ensure fire drills are conducted. ED and Maintenance Director will be responsible for calendar reminders, that will give Community a chance to reschedule if needed.