VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Williamsburg
236 Commons Way
Williamsburg, VA 23185
(757) 564-4433

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Sept. 13, 2023 , Oct. 27, 2023 and Nov. 1, 2023

Complaint Related: Yes

Areas Reviewed:

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint An on-site complaint inspection was conducted on 9-13-23 (AR 15:45 /dep 16:30) 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 (9-8-23 and 9-13-23) regarding allegations of physical abuse/neglect/ inappropriate behavior by peer). 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. SCU Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 6 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the allegation but identified during the course of the investigation can 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 (Willie Barnes), Licensing Inspector at (757)- 439-6815 or by email at willie .barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1100-A
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure prior to placing a resident with a serious cognitive impairment due to primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval of one of the individuals noted in the order of priority noted in the regulation. Evidence: 1. On 9-13-23, resident #1?s record did not have documentation of the resident, a guardian or legal guardian, relative or an independent physician. 2. The resident?s record did include a copy of the resident?s power of attorney. But Based on record reviewed and staff interviewed, the facility failed to ensure prior to placing a resident with a serious cognitive impairment due to primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval of one of the individuals noted in the order of priority noted in the regulation. Evidence: 1. On 9-13-23, resident #1?s record did not have documentation of the resident, a guardian or legal guardian, relative or an independent physician. 2. The resident?s record did include a copy of the resident?s power of attorney. But the resident?s record did not have documentation of written approval in the resident's record from the legal representative.
Plan of Correction:	Education was given to NP of appropriate form to sign for placement in a secure unit. NP demonstrated understanding of education and was assured that going forward to adhere to the regulation not able to sign as independent physician if a legal guardian is present. POA notified and voiced they were in agreement of the placement and will sign approval for placement. To be corrected 11/09/23 Audit of all medical records in Memory care to ensure appropriate approvals are present . completion 11/17/23
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs. Evidence: 1. On 9-13-23, resident #1?s uniform assessment instrument (UAI) dated 2-2-23 noted bathing need assessed as no help need. The ISP dated 4-13-23 noted, ?use of grab bar when getting in and out of shower?may require reminding or standby assist for safety?. Walking assessed as human help/supervision; this need is not documented on the ISP. Wheeling assessed as not performed. These items not documented on the ISP. The ISP noted resident ?uses cane when rollator is not is use?. The resident was observed walking in the facility without the use of a cane or rollator. The ISP noted resident ?has current or history of frequent anxiety and agitation?, however the ISP did not document what services were to be provided to address this psychosocial need. The resident?s physical examination dated 2-16-23 noted resident allergic to Iodine, Oxycodone, Percocet, Avac-E, Sulfa and Cipro. The ISP noted, ?does not have any known food or drug allergies?. The clinical/progress notes dated 8-2-23 documented resident receives podiatry services; this service was not on the ISP. 2. Resident #2?s progress notes dated 7-13-23 noted a ?new order for PT/OT/Speech Therapy due to recent afib?. Order fax to a local home health agency and POA notified. Speech therapy (ST) visit noted in progress note on 8-1-23 and 8-8-23. Occupational Therapy (OT) visit noted on 9-7-23, no change to current care plan. Progress notes dated 4-12-23 and 7-19-23 noted the resident received podiatry services. This service was not on the resident?s ISP.
Plan of Correction:	Resident #1 uniform assessment and individualized service plan have been updated with provision to reflect accurate assessed needs of resident. Mechanical and standby assistance for shower and no supervision when ambulating. Psychological need for anxiety and agitation services have been addressed in updated ISP as well as use of Podiatry services. Allergies (food and drug) have been added to the current plan ISP. Corrected 11/8/23. 2) Resident #2 ISP has been updated with Therapy services completed on 9/22/23. Corrected 11/8/23. Monthly review and audit of resident ISP and UAI to ensure assessed needs are accurate ? RCD/Designee to be completed -11/15/23- ongoing.