VIRGINIA DEPARTMENT OF SOCIAL SERVICES

COMMONWEALTH SENIOR LIVING AT GLOUCESTER HOUSE
7657 Meredith Drive
Gloucester, VA 23061
(804) 693-3116

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: July 11, 2023 and July 12, 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 22VAC40-80 THE LICENSE

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: 7/11/2023 9:00am - 4:30 pm an 7/12/2023 10:06 am - 5:10 pm 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: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 5 Observations by licensing inspector: Several of the areas the Licensing Inspector observed were meals, activities, and physical plant conditions. Additional Comments/Discussion: N/A 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 Alyshia E. Walker, Licensing Inspector (757)670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-120-C
Description:	Based on record review and staff interview, the facility failed to ensure that all staff shall receive orientation and training in all required areas of this standard within the first seven working days of employment. Evidence: 1. The orientation documentation for Staff # 3 did not include documentation the staff member had been oriented on the emergency and disaster plans, procedures for handling resident emergencies, and use of the first aid kit and its location. 2. Staff # 6 acknowledged the orientation form for Staff #3 was blank in the aforementioned areas.
Plan of Correction:	Staff # 3 orientation to emergency and disaster plans, procedures for handling resident emergencies and use of the first aid kit and its location has been corrected 7/13/23. Audit of current employee files will be completed by 8/15/2023 to assure documentation of training is available per regulatory standards.
Standard #:	22VAC40-73-310-H
Description:	Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without a treatment plan. Evidence: 1. Resident #6 was prescribed Diazepam and Lorazepam and the file provided to the Licensing Inspector did not contain psychotropic treatment plans for those medications. 2. Resident # 5 was prescribed Seroquel and the file provided to the Licensing Inspector at the time of the inspection did not contain a psychotropic treatment plan for that medication. 3. Staff # 3 verified the files did not contain the psychotropic treatment plans.
Plan of Correction:	Resident #5 and #6 psychotropic treatment plan?s were sent to doctor for signature . At admission and with new orders, for psychotropic medications, RCD/ designee will ensure treatment plans are available and updated to include appropriate medications. An audit of current residents will be completed to assure treatment plans are available for current psychotropic medications. This audit will be completed by 8/15/2023.
Standard #:	22VAC40-73-320-B
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure a risk assessment for tuberculosis was completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: The TB Risk Assessment provided for Resident # 6 did not have an assessment date. The undated TB Risk Assessment had a signature from the nurse practitioner that was pre-signed. The last dated TB Assessment in the resident?s file was dated 10/18/2021.
Plan of Correction:	Resident #6 did not have an updated TB risk assessment. This has been corrected 7/21/23. TB risk assessments will be completed prior to admission and at least annually and placed in resident record. RCD/designee will ensure assessments are in resident record. An audit or current resident will be completed by 8/31/23.
Standard #:	22VAC40-73-380-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the personal and social information document was kept current. Evidence: 1. The social data form for Residents # 1, 4 and 5 did not include a complete listing of the residents? allergies. 2. The social data form for Resident #7 did not state the resident?s code status.
Plan of Correction:	Residents 1,4,5,7 will have their social data forms updated with allergies and code status. Upon admission, and with change in information provided, RCD/ED/designee will ensure that all areas of the social data have correct information. An audit of these records will be completed by 8/15/23.
Standard #:	22VAC40-73-450-A
Description:	Based on record review, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: 1. The preliminary plan of care for Resident # 2 identified the resident?s need for assistance in the area of bathing, grooming, dressing, toileting/incontinence, transferring, meal preparation, money management, housekeeping, medication management, but there are no dates the needs were identified. The need of bathing on the preliminary plan for the resident #2 states both that the resident needs assistance and does not need assistance. The initial UAI for the resident states the resident needs physical assistance in the area of bathing. The need of transferring on the preliminary plan of care for resident #2 states the resident did not need any assistance however the initial UAI for the resident states the resident requires supervision. The needs of walking and wheeling on the preliminary plan of care for Resident #2 does not state the type of assistance the resident requires. The initial UAI states the resident requires supervision in the area of walking and does not require any assistance in the area of wheeling. The DNR section on the initial plan of care for Resident #2 does not state if the resident has a DNR or does not have a DNR. 2. The preliminary plan of care for Resident # 3 identified the resident?s need for assistance in the area of bathing but no type of assistance was identified. The initial UAI for Resident #3 assessed the resident as needing mechanical and physical assistance in those areas. The preliminary plan for Resident #3?s dressing assistance was blank. The initial UAI for the resident assessed the resident as needing mechanical and physical assistance in this area. The preliminary plan for Resident #3?s toileting/incontinence was blank. The initial UAI for the resident assessed the resident as needing mechanical and supervision in this area. The preliminary plan for Resident #3?s walking and wheeling assistance was blank. The initial UAI for the resident assessed the resident as needing mechanical and supervision assistance in walking and the resident needs supervision when wheeling. 3. The preliminary plan of care for Resident #1 did not document the resident?s services of skilled nursing, physical therapy, and speech therapy all of which the resident was receiving.
Plan of Correction:	#1 Resident #2 preliminary plan of care did not have date identified. The preliminary care plan did not address bathing, transferring, walking wheeling as compared to the UAI. Resident #2 does not have a documented DNR . This was corrected 7/25/23. Upon admission ED/RCD will ensure that items on the preliminary care plan match the UAI and speaks to resident?s needs. An audit of current records will be completed by 8/31/23. #2 Resident #3 Preliminary plan of care does not have ADL care addressed as compared to the UAI. This has been corrected 7/25/23. Upon admission ED/RCD/designee will ensure that items on preliminary care plan match the UAI and speaks to resident?s needs. An audit of current residents will be completed by 8/31/23. Resident # 1 preliminary care plan did not document third party services that the resident was receiving. This was corrected 7/26/23. Upon admission, and within initial 30 days post move-in, the ED/ RCD/designee will ensure that third-party services are addressed and accurate to services being provided. An audit of current residents will be completed by 8/31/23
Standard #:	22VAC40-73-450-F
Description:	Based on resident records review and staff interview, the facility failed to ensure the individualized service plans (ISP) updated as needed for a significant change of a resident?s condition. Evidence: 1. Resident # 1?s UAI dated 5/17/23 assessed bathing as human help/physical assistance. The ISP dated 6/28/23 documented the resident needed mechanical and physical assistance. 2. Resident #1?s UAI assessed dressing as mechanical and supervision. The ISP documented the resident needed physical assistance. 3. Resident #1?s UAI assessed the resident as needing mechanical and supervision for transferring. The ISP documented the resident needed supervision.
Plan of Correction:	Resident #1 UAI does not reflect the same needs as on the ISP. This was corrected 7/27/23. ED/RCD/Designee will assure that the UAI and ISP match and speak to the current needs of the resident. An audit of current residents will be completed by 8/31/23.