VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at the Eastern Shore
23610 North Street
Onancock, VA 23417
(757) 787-4343

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Dec. 5, 2023

Complaint Related: Yes

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 22VAC40-80 COMPLAINT INVESTIGATION

Technical Assistance:

Mental Health Screening

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: An unannounced complaint inspection took place on 12/05/2023 from 10:58 am to 3:05 pm. 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 (11/20/2023) regarding allegations in the area(s) of: Resident Care and Related Services, Building and Grounds, and the Safe Secure Environment. Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: An observation of residents and activity was observed in the safe, secure environment. A review of the staffing schedule and communication logs was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the (complaint(s)/self-report) 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 Donesia Peoples. Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1090-A
Complaint related:	No
Description:	Based on the record review the facility failed to ensure prior to admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. The record of Resident #4 contains an assessment of serious cognitive impairment dated 03/28/22 which includes a response of ?No? for the question ?is the individual named above unable to recognize danger or protect his/her own safety and welfare.? Resident?s #4 record contains an approval and placement in the safe secure environment dated 04/10/22. The facility?s record includes resident #4 as residing in the safe, secure environment.
Plan of Correction:	What Has Been Done to Correct? Resident #4?s assessment now reflects ?yes? to the answer to the question, ?Is individual named above unable to recognize danger or protect his/her own safety and welfare.? How Will Recurrence Be Prevented? The RCD/designee will complete an audit of current residents residing in safe, secure environment to assure appropriate documentation is available as per regulatory requirements. Moving forward, prior to admission to safe, secure environment the ED will assure that appropriate documentation has been received as proof that resident has been appropriately assessed by either a licensed clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to diagnosis of dementia. If documentation has not been received, the ED will assure admission is delayed until documentation of the assessment is available and reviewed by the ED/designee.
Standard #:	22VAC40-73-930-D
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure for each resident with an inability to use the signaling device the following shall be met: once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum direct care staff shall make rounds no less than every two hours; the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. The documentation shall be retained at the facility for two years. Evidence: 1. Resident?s #1 Individualized Service Plan (ISP) dated 11/22/23 includes the ?resident requires reminding with how to use the emergency response system. Direct care staff will make rounds every 2 hours to ensure that all care needs are met.? Resident?s #1 record did not include documentation rounds were made for Nov. 2023 and during the timeframe of 12/03/23-12/04/23. 2. Resident?s #2 ISP dated 09/13/23 includes the ?resident is unable to use the call light system located in apartment and restroom. Staff will complete visual checks on resident every 2 hours during hours of sleep to ensure safety care needs are met.? Resident?s #2 record did not include documentation rounds were made for the month of Nov. 2023 and during the timeframe of 12/01/23-12/04/23. 3. Resident?s #4 ISP dated 09/30/23 includes the ?resident is unable to use the call light system located in apartment and restroom. Staff will complete visual checks on resident every 2 hours during hours of sleep to ensure safety care needs are met.? Resident?s #4 record did not include documentation rounds were made for the month of Nov. 2023 and during the timeframe of 12/03/23-12/04/23.
Plan of Correction:	What Has Been Done to Correct? Resident #1, Resident #2 and Resident #4 all now have evidence of documented rounding every two hours to include the name of the resident, date and time of the rounds and the staff member who made the rounds as required to ensure needs are met. How Will Recurrence Be Prevented? Training provided to new and current direct care staff on how to appropriately document every 2 hour checks for those residents that are unable to utilize community signaling device. ARCD will conduct routine audit to assure that documentation logs are being completed for each resident at least every 2 hours, as appropriate for those residents unable to signal for assistance. RCD will conduct overlapping routine audit to assure that logs are being completed. For the next 30 days, the ED will conduct routine audit on rounding logs to include Assisted Living and Memory Care.