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: Dec. 1, 2023

Complaint Related: Yes

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: 10/26, 27/2023 Approximate time on 10/26/2023-11:04a.m-1:24p.m. On 10/27/2023 approximate time 11:59-2:46p.m 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 09/29/2023 regarding allegations in the areas of Resident Care and Related Services 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. Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: 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 in medication administration and Food Service and Nutrition A violation notice was 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) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-580-F
Complaint related:	No
Description:	Based on the review of facility records and staff interviews the facility failed to implement interventions for a resident as soon as a nutritional problem is suspected. Evidence: Resident #1 Facility records submitted for the inspector?s review revealed that the resident had significant weight loss beginning 02/02/2023 weighing 181lbs; 03/02/2023 the resident?s recorded weight is 154lbs and 04/04/2023 the facility recorded the weight as 138lbs. Upon request the facility did not submit for the inspector?s review documented evidence that interventions were put in place to address the resident?s ongoing weight loss prior to 09/13/2023.
Plan of Correction:	FACILITY'S RESPONSE: "When the community documents 5 pounds or 5% greater weight loss of a resident in 30 days, weight will be rechecked to ensure accuracy of reading by Resident Care Director or designee. If the weight loss is duly documented, physician will be notified upon identification, and any new orders implemented. Dietician consult will be initiated, and interventions monitored and documented. UAI and ISP will be updated accordingly."
Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order. Evidence: Resident #1 The facility July 2023 medication administration records (MARs) for the resident that was submitted for the inspector?s review did not include the 325mg of the medication Oxycodone that was prescribed by the resident?s physician.
Plan of Correction:	FACILITY'S RESPONSE: " Documenting in MAR within 24 hours of receipt of new order ? When the community receives a new order for medications for a resident, the community will ensure transcription as per physician order and documentation of the order in the Medication Administration Record within 24 hours. This is the responsibility of the Resident Care Director or designee. Medication associates will be re-educated by the Resident Care Director or designee on the medication management plan. Random audit will be completed by Resident Care Director or designee weekly for 4 weeks on new medication orders for verification of transcription and documentation as per physician order."