VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Front Royal
600 Mount View Street
Front royal, VA 22630
(540) 636-2800

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: Oct. 18, 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

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: LI entered the facility at 8:25 am on 10/18/2023 and exited the facility at 3:00 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: 85 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: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed medication administration. Additional Comments/Discussion: 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-250-C
Description:	Based upon a review of records, the facility failed to ensure that an original criminal record check and sworn disclosure statement were included in each staff record. Evidence: 1. During the renewal inspection conducted on 10/18/2023, completed sworn disclosure statements were not found for Staff #21, #23, and #31. 2. Original criminal record checks were not found in the staff records for Staff #6 and Staff #26.
Plan of Correction:	Staff Health Records and Requirements Based upon review of the Staff health records and requirements, the assisted living facility shall provide an original criminal record report and a sworn disclosure statement. Copies of the original criminal record report and sworn disclosure statements to be kept in the staff record. All new staff members will have an original criminal record report and a sworn disclosure statement completed and filed in their records. Will conduct an audit of all current staff members for original criminal record report and a sworn disclosure statement to be completed by the community by 11/10/2023. Will monitor for continued compliance by weekly monitoring with digital audit tracking log. Title of Responsible person(s) Business Office Manager or Designee. Executive Director or Designee to spot check new staff members? records monthly x3 months to ensure compliance.
Standard #:	22VAC40-73-260-A
Description:	Based upon a review of records, the facility failed to ensure that each direct care staff member maintained current certification in first aid. Evidence: 1. The employee record for Staff #5 did not contain current first aid certification.
Plan of Correction:	First Aid and CPR certification Based on review of staff?s first aid and CPR certification, The assisted living facility should ensure that each direct care staff member shall maintain a current first aide certification within 60 days of employment that is to be kept in the staffs? records along with a posting that is easily accessible. A 100% audit will be completed on 11/3/2023 and any direct care staff that is in need of first aide/CPR course will be enrolled in the 11/9/2023 course to ensure compliance. As new employees are hired, they will be enrolled in the next monthly course that is scheduled closest to their hire date. Will monitor for continued compliance by weekly monitoring with digital audit tracking log. Title of Responsible person(s) Business Office Manager or Designee. Executive Director or Designee to spot check CPR compliance by reviewing Audit tracking log as well as certification in staff records monthly x3 months.