VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Kilmarnock
460 S. Main Street
Kilmarnock, VA 22482
(804) 435-9896

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

Inspection Date: Sept. 20, 2023 and Sept. 26, 2023

Complaint Related: No

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: On 09/20/2023 approximate time 10:35a.m-5:02p.m. On 09/26/2023 approximate time of 11:00a.m-2:44p.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: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 5 Observations by licensing inspector: Medication administration observation conducted on 09/26/2023. 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at angela.r.reaves@dss.virginia.gov Violation Notice Issued: Yes

Violations:

Standard #:	22VAC40-73-1110-B
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that an annual review of the appropriateness of each resident's continued residence in the special care unit was conducted. The review of the facility?s most recent assessment for continued place in the special care unit of the facility on 09/20, 26/2023 revealed the following: Resident #2-Documented date of admission- 11/03/2017-most recent assessment dated 01/20/2019. Resident #3- Documented date of admission -1/21/2021-most recent assessment dated 03/09/2022. Resident #4- Documented date of admission-12/19/2022-no documented evidence that continued placement review had been conducted. The facility did not submit for the inspector?s review documented evidence that annual review of the appropriateness of continued placement in the special care unit was conducted for resident #s 2, 3 and 4.
Plan of Correction:	FACILITY'S RESPONSE: "Resident #2 appropriateness of placement and continued residence was updated on 10/15/23 and Resident #3approprateness of placement was updated o 9/27/23. Appropriateness of placement for all residents in a special care unit will be completed upon admission, six months after admission, and annually. Reviews will be submitted to the Quality Assurance Committee for two quarters. Executive Director and/or Resident Care Director"
Standard #:	22VAC40-73-220-A
Description:	Based on the review of facility records, facility and staff interviews the facility failed to ensure that all of the required elements are met when private duty personnel from licensed home care organizations provide direct care or companion services to residents in an assisted living facility. Evidence: Resident #1- Documented date of admission: 11/21/2016 The facility did not submit for the inspector?s review documented evidence that the direct care or companion services provided by private duty personnel to meet identified needs was reflected on the resident's 04/11/2023 individualized service plan, that the private duty personnel was provided orientation and training regarding the facility's policies and procedures related to the duties of private duty personnel and that documented that the private duty personnel was free of tuberculosis in a communicable form.
Plan of Correction:	FACILITY'S RESPONSE: "Resident #1 private duty aid completed orientation and training regarding the facility's Policies and Procedures on 11/9/23 which included a screening to be free from communicable diseases. All private duty aides will complete the orientation and training of the facility policies and procedures upon hire as well as provide a screening to be free from communicable diseases. Reviews will be submitted to the Quality Assurance Committee quarterly. Executive Director and/or Resident Care Director will maintain files on private duty aides."
Standard #:	22VAC40-73-250-D
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that each staff person was evaluated annually and submitted the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Staff #1-documented date of hire 04/02/2022-Most recent TB examination documentation that was submitted for the inspector?s review is dated 03/20/2022 Staff #2-documented date of hire 03/04/2020- Most recent TB examination documentation that was submitted for the inspector?s review is dated 02/11/2022
Plan of Correction:	FACILITY'S RESPONSE: "Staff #1 and staff #2 TB documentation was updated on 10/15/23. All new hire TB screenings will be completed upon hire and then annually thereafter. New and current staff will have the annual TB screening completed each October. Reviews will be submitted to the Quality Assurance Committee quarterly. Executive Director and/or Resident Care Director will maintain TB documentation on staff."
Standard #:	22VAC40-73-320-B
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that 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: Resident #1-Documented date of admission 11/21/2016- No documentation that an annual TB risk assessment has been conducted. Resident #2-Documented date of admission 11/03/2017- Most recent TB examination documentation that was submitted for the inspector?s review is dated 03/16/2022. Resident #6-Documented date of admission 03/16/2021- No documentation that an annual TB risk assessment has been conducted.
Plan of Correction:	FACILITY'S RESPONSE: "Resident #1, Resident #2, and Resident #6 TB documentation was updated on 10/15/23. New and current resident's TB documentation will be completed on admission and annually. Reviews will be submitted to the Quality Assurance Committee quarterly. Resident Care Director and/or designees"
Standard #:	22VAC40-73-440-H
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that annual reassessments and reassessments due to a significant change in the resident's condition, using the UAI, is utilized to determine whether a resident's needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. The facility did not submit for the inspector?s review documented evidence that an annual assessment was conducted. Evidence: Resident #2- Documented date of admission 11/03/2017 Upon request on 09/ 20, 26/2023 to review the resident?s most recent UAI the facility submitted a UAI dated 07/22/2022.
Plan of Correction:	FACILITY'S RESPONSE: "Resident #2 UAI was updated on 10/12/23. All resident's UAI?s will be completed annually or when there is a significant change in the condition of the resident. Monitoring of UAI?s will be submitted quarterly to the Quality assurance committee. Resident Care Director or designee"
Standard #:	22VAC40-73-450-F
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that an individualized service plan (ISP) was updated as needed for a significant change of a resident?s condition in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons. Evidence: 1-Resident -Documented date of admission 11/21/2016 ?The resident?s 04/11/2023 ISP notes under the heading Neurocognitive that the resident is oriented in all spheres. A separate entry on the ISP under the heading Neurocognitive notes that the resident has current or history of occasional difficulty remembering and using information, requires some directions and reminding from others, may have difficulty following written instructions.? The resident?s 04/11/2023 ISP notes under the heading psychosocial that the resident has current or history of occasional mood disorder and that facility direct care staff will provide the service but the ISP does not identify what the specific services are. The facility however, reassessed the resident on 04/10/2023 as being oriented in all spheres, appropriate psycho-social behaviors and not in need of a psychiatric or psychological evaluation. ?The facility?s Summary of Nutritional review document dated 07/18/2023 for resident #1 notes in part ?continue assisting with meals as needed?. The resident, however, was assessed on 04/10/2023 by facility staff as being independent with eating/feeding. On 09/2020 during the lunch time meal the inspector observed the resident?s private sitter cutting up and queuing the resident to take bites of food. The residents? 04/11/2023 care plan was not updated to identify the individualized services that facility staff are responsible for providing based on the residents? actual assessed needs. RESIDENT #2: Documented date of admission 11/03/2017 Upon request on 09/ 20, 26/2023 to review the resident?s most recent ISP the facility submitted an ISP dated 07/22/2022. The facility did not submit for the inspector?s review documented evidence that an annual individualized service plan had been developed for resident #2.
Plan of Correction:	FACILITY'S RESPONSE: "Resident #1 ISP was updated on 10/10/23 to reflect the resident?s current neurocognitive state and psycho-social behaviors. Resident #2 ISP was reviewed and updated on 4/11/23 and 10/12/23. Current resident ISPs will be reviewed and updated at least annually or as needed for a significant change in a resident?s condition. Reviews will be submitted to the Quality Assurance Committee for the next two quarters. Resident Care Director and/or designee"
Standard #:	22VAC40-73-580-F
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that notification to the attending physician if a significant weight loss is identified in any resident who is not on a physician-approved weight reduction program and obtaining, documenting, and following the physician's instructions regarding nutritional care. Evidence: 1-Resident-Documented date of admission 11/21/2016 The facility?s monthly weight document noted the following weights for the resident: April 2023=137.2lbs, May 2023=134.2lbs, June 2023=132.5lbs, July 2023=124.6lbs, August 2023=127.0lbs, September 2023=121.6lbs. The Summary of Nutritional review document dated 07/18/2023 for resident #1 notes in part ?noted 12.6 lb. weight loss in three months, a 9% loss.? The facility?s June, July and August 2023 progress notes documentation that was submitted for the inspectors? review did not identify that the resident?s physician was notified of the resident?s significant weight loss as determined by the 07/18/2023 dietician?s report and the facility?s monthly weight reporting and received written instruction regarding nutritional care for the residents? ongoing weight loss.
Plan of Correction:	FACILITY'S RESPONSE: "Resident #1 received an order for a nutritional supplement on 5/27/23. The resident was provided snacks between meals, and staff support at mealtime. ISP updated to reflect resident needs for support at mealtime. The physician and dietician were contacted on 11/8/23 for a medication review. Current residents will be monitored monthly for weight and the facility will implement appropriate interventions per physician notification and orders. Monthly weights and dietician reviews will be submitted to the Quarterly Quality Assurance Committee for two quarters. Resident Care Director and/or designee"