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 15, 2023 , May 22, 2023 and June 15, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: May 15, 2023 ? 9:30 a-12:15p; May 22, 2023, 9:30 a; and June 15, 2023 11:40 a 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 (10/06/2022) regarding allegations in the area(s) of: Resident Care and Related Services 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: 1 Number of staff records reviewed:0 Number of interviews conducted with residents:4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Physical plant, Dietary, Medication Administration, Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were 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) 662-9743 or by email at angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-460-H
Complaint related:	Yes
Description:	22 VAC 40-73-460-H (Complaint Related) Based on record review and interviews, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met. Evidence: During inspections conducted on May 22, 2023, and May 25, 2023, and June 15, 2023, the record for Resident #1 did not contain documentation/evidence of assistance with Bathing at least twice a week. Excerpts from Progress Notes for Resident #1 indicated the following: ?06/09/2022 ? Resident refused assistance from care aide?.?; ?07/08/2022 ? Resident received shower this shift?; ?07/14/2022 ? Resident received shower this shift?; ?07/20/2022 ? Resident refused shower x3 this shift??; and ?09/06/2022 ? Resident received shower...? Interviews with Staff #1 and Staff #2 confirmed the facility was unable to provide additional documentation regarding showers provided to the resident.
Plan of Correction:	The community will ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met. The community will maintain a shift-to-shift report sheet in which staff can communicate with each other each shift. Staff will acknowledge completion of care and write exceptions to care on the shift-to-shift report sheet, including refusal of a shower. RCD or designee will review the shift-to-shift communication report sheet at least daily when in the community. RCD or designee will document in resident record to reflect notification to family regarding refusal of showers.
Standard #:	22VAC40-73-470-A
Complaint related:	Yes
Description:	Based on record review, observation, and interview, the facility failed to ensure, either directly or indirectly, that the health care needs of the residents are met. Evidence: During inspections conducted on May 22, 2023, and May 25, 2023, the record for Resident #1 contained a physician?s order for urinalysis screen to be obtained on June 14, 2022. The facility was informed by collateral via email that the urinalysis sample was not collected on June 18, 2022, July 2, 2022, and July 17, 2022. The facility failed to follow-up by obtaining the urinalysis sample until July 17, 2022, which was 33 days later. The resident was confirmed to have a urinary tract information (UTI) on July 18, 2022. Interviews with Staff #1 and Staff #2 confirmed the home health care company failed to collect the sample as requested, but the facility also failed to follow-up to ensure the service was completed in a timely manner.
Plan of Correction:	The community will ensure, either directly or indirectly, that the health care service needs of residents are met. The community contracts with a medical laboratory who regularly collects, picks up and processes resident laboratory orders. If the laboratory order is not completed or laboratory does not pick up as scheduled, Resident Care Director (RCD) or designee will communicate with family and doctor and execute any new orders given by the physician for prompt service. RCD or designee will discuss new laboratory orders pending completion during Leadership Meeting until matter is resolved. Incoming faxed orders for laboratory work will be placed in RCD?s inbox and reviewed by RCD or designee when in the community. RCD or designee will ensure that the laboratory orders are communicated with the laboratory via their preferred method of communication for action and completion.