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: Dec. 5, 2023 , Jan. 31, 2024 , Feb. 16, 2024 and Feb. 22, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 63.2 PROTECTION OF ADULTS AND REPORTING 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint An on-site complaint inspection was conducted on 12-5-23. (Ar 10:00/ Dep 4:45 p.m.) The facility census was 53. 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 10-11-23 regarding allegations in the resident care and related services. Number of residents present at the facility at the beginning of the inspection: 53 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 9 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 complaint 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 #:	22VAC40-73-310-H
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure in accordance with 63.2-1805- D of the Code of Virginia, it did not admit or retain individuals with any of the prohibited conditions or care needs for a resident. Evidence: 1. On 12-5-23, resident #1?s record included a physician?s order dated 9-26-23 for Zoloft. The resident?s physician?s order sheet (POS) dated 9-19-23 noted resident?s order for Zoloft. The resident?s record did not include a psychotropic treatment plan. 2. Staff #1 acknowledged the resident?s record did not have a psychotropic treatment plan for Zoloft.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-430-H-1
Complaint related:	No
Description:	Based on observation and staff interviewed, the facility failed to ensure at the time of discharge, the assisted living facility shall provide to the resident and, as appropriate, the legal representative and designated contact person a dated statement signed by the licensee or administrator. A copy of the written statement shall be retained in the resident?s record. Evidence. 1. On 12-5-23, staff #1 informed the inspector, the resident was no longer in the facility and had been discharged. A request for a copy of the discharge statement was requested as it was not with the other documents presented. The discharge statement provided was incomplete. 2. Staff #1 acknowledged the discharge statement was not completed prior to the inspector?s request for a copy on 12-5-23.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
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 for a resident. Evidence: 1. On 12-5-23, resident #1?s physical examination dated 11-1-22 documented physical therapy and occupational therapy evaluation and treatment. The record also included an order dated 6-19-23 for physical therapy and occupational. The record noted occupational and physical therapy services from a local health care provider. These services were not documented on the resident?s ISP dated 11-30-22. The resident?s record included psychological consults with a licensed therapist. This mental health service was documented on the resident?s ISP. The resident?s ISP documented resident was to be withheld cardiopulmonary resuscitation (CPR). The resident?s record did not include a signed and dated Do Not Resuscitate (DNR) order. 2. Resident #1s record documented the resident was admitted on 11-28-22 and was sent to a local hospital on 8-16-23 followed by a stay in a local rehabilitation facility following hip surgery. The resident returned to the facility on 9-18-23. The resident?s ISP was not updated to reflect resident?s change of condition. The ISP review dated was not 12-30-22. 3. Staff #1 acknowledged the resident?s ISP was not updated to address resident?s care needs.
Plan of Correction:	Not available online. Contact Inspector for more information.