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: Jan. 25, 2024

Complaint Related: No

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/22/2024 Approximate time 11:04a.m-4:55p.m. On 01/25/2024 approximate time 10:42a.m-2:00p.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: 61 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: 6 Number of interviews conducted with residents: Number of interviews conducted with staff: 5 Observations by licensing inspector: A noontime medication observation was conducted on 01/25/2024. 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.

Violations:

Standard #:	22VAC40-73-1150-B
Description:	Based on the review of facility records, facility surveillance video and staff interviews, the facility failed to ensure that protective devices on the bedroom windows of residents and on windows in common areas accessible to residents prevents the windows from being opened wide enough for a resident to crawl through. The protective devices on the windows shall be in conformance with the Virginia Uniform Statewide Building Code (13VAC5-63). Evidence: Resident #5-Documented date of admission 03/09/2020 The facility reported to the regional licensing office that on 12/17/2023 the resident was able to remove the screws from his bedroom window, climb through the window with his rollator and elope from the facility. The resident was seen in the front parking lot of the facility and returned to the building. The facility did not ensure that a protective device was on the bedroom window that prevented the resident from climbing out of the window and eloping.
Plan of Correction:	FACILITY'S RESPONSE: "Facility shall ensure that protective devices are on all windows in memory care to prevent the windows from being opened wide enough for a resident to crawl through. Response: All windows in the memory care neighborhood have been inspected to ensure that protective devices are in place and in good working order. Maintenance Director will audit the windows in the memory care neighborhood once a week for 4 weeks, and then once a month for the next 2 months."
Standard #:	22VAC40-73-320-A
Description:	Based on the review of facility records the facility failed to ensure that within the 30 days preceding admission, a person must have a physical examination by an independent physician. The report of such examination must be on file at the assisted living facility and must contain all of the required information. Evidence: Resident #1-Documented date of admission 12/21/2023 The resident?s 12/14/2023 health and physical examination report reviewed with the Administrator did not have the statement that the resident does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H and did not document whether the resident is or is not capable of self- administering medication.
Plan of Correction:	FACILITY'S RESPONSE: "The facility will ensure that within the 30 days preceding admission, a person must have a physical examination by an independent physician. The report of such examination must be on file at the assisted living facility and must contain all of the required information. Response: The Executive Director (ED) and Resident Care Director (RCD) will review all health and physical examination reports prior to the arrival of any new admission to ensure that all questions are answered appropriately on the form. New admission files will be audited every 2 weeks for 1 month, and then once a month for the next 2 months."
Standard #:	22VAC40-73-440-B
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that the Uniform Assessment Instrument (UAI)s for private pay individuals was completed by a qualified assessor. Evidence: Resident #1-Documented date of admission 12/21/2023 The resident?s 01/15/2024 reassessment UAI that was reviewed with the Administrator is not signed and the signature lines are blank.
Plan of Correction:	FACILITY'S RESPONSE: "The facility will ensure that the Uniform Assessment Instrument (UAI)s for private pay individuals be completed by a qualified assessor. Response: ED and RCD will ensure that UAI?s are completed and properly signed for both initial assessments and reassessments. UAI?s will be audited every 2 weeks for 1 month, and then once a month for the next 2 months."
Standard #:	22VAC40-73-450-C
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that a comprehensive individualized service plan was completed within 30 days after admission. Evidence: Resident #1-Documented date of admission 12/21/2023 It was revealed during the review of the resident?s facility records on 01/22/2024 with the facility Administrator that a comprehensive ISP had not been developed for the resident. The resident?s 12/14/2023 health and physical examination report document notes therapy orders for physical therapy 4 times a week and occupational therapy for 3 times a week. The resident?s 11/15/2023 preliminary ISP is not documented to identify a plan of care to address the physician?s order for physical and occupational therapy. Resident #2-Documented date of admission 06/29/2023 Upon request to review the most recent ISP for the resident the Administrator submitted a 06/28/2023 document titled Virginia Health and services Evaluation Results. Based on the review of the document with the facility Administrator the document does not identify that a plan of care had been developed based on the resident?s assessed needs. The facility did not submit upon request while onsite at the facility on 01/22, 25/2024 documented evidence that a comprehensive ISP had been developed for resident #2
Plan of Correction:	FACILITY'S RESPONSE: "The facility will ensure that a comprehensive individualized service plan be completed within 30 days after admission. Response: ED and RCD will ensure that a comprehensive ISP be developed for each resident within 30 days of admission. Such ISP will include plan of care to address resident specific needs. New admission ISPs will be audited every 2 weeks for 1 month, and then once a month for the next 2 months."
Standard #:	22VAC40-73-450-D
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization communicated and established an agreed upon coordinated plan of care for the resident. The services provided by each must be included on the individualized service plan (ISP). Evidence: Resident #1- Documented date of admission 12/21/2023 The facility Administrator stated during the 01/22/2024 interview and during the review of facility records that at admission resident #1 was receiving hospice services. The resident?s 12/15/2023 preliminary ISP is not documented to note that the resident is receiving hospice services and does not identify the services that the hospice agency will be providing.
Plan of Correction:	FACILITY'S RESPONSE: "The facility will ensure that when hospice care is provided to a resident that the assisted living facility and the licensed hospice organization communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each must be included in the ISP. Response: ED and RCD will ensure that the ISP is comprehensive and includes any services that an outside agency is providing to a specific resident. ISPs will be audited every 2 weeks for 1 month and then once a month for the next 2 months."
Standard #:	22VAC40-73-450-F
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that Individualized service plans are reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: Resident #2-Documented date of admission 06/29/2023 The facility did not submit upon request while onsite at the facility on 01/22, 25/2024 documented evidence that an ISP had been developed for resident #2 that identifies the ongoing home health services that the resident is receiving.
Plan of Correction:	FACILITY'S RESPONSE: "Facility will ensure that ISPs are reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Response: ED and RCD will ensure that ISPs are reviewed and updated at least once every 12 months and as needed for a significant change in a resident?s condition. ISPs will be audited every 2 weeks for 1 month and then once a month for the next 2 months."
Standard #:	22VAC40-73-870-A
Description:	Based on observation the facility failed to ensure that the interior of the building is maintained in good repair. Evidence: The following was observed during the walk through of the facility with the Administrator on 01/22/2024: ? The hallway near room #s 323 and 328 were observed to be uneven. ? At approximately 11:51a.m a resident?s breakfast plate that was observed to have two pieces of uneaten toast, eggs and bacon was left uneaten in a residents? room. ? Several resident rooms were observed to have clothing scattered about the room and resident toiletries scattered about the bathrooms.
Plan of Correction:	FACILITY'S RESPONSE: "Facility will ensure that the interior of the building is maintained in good repair. Response: ? Hallway floor near rooms 323 and 328 was observed to be uneven. The issue is currently under evaluation to discover the scope of the repairs needed to the affected area. Currently there is no immediate danger of the floor falling since the design is concrete board on top of plywood. Contractor will be on site on February 20, 2024. We anticipate a plan and scope of work by March 4, 2024. We will keep DSS updated as we have additional plans/dates. ? Dining staff and Resident Care Aides will pick up dining room dishes in resident rooms within 1 hour of delivery of meal. RCD or designee will audit rooms daily for 2 weeks to ensure that all dining room dishes are promptly removed. ? Housekeeping staff and Resident Care Aides will ensure resident rooms and bathrooms are neat and orderly. RCD or designee will audit rooms daily for 2 weeks to ensure rooms are maintained in a neat and orderly fashion."
Standard #:	22VAC40-73-870-B
Description:	Based on observation the facility failed to ensure that all buildings are free from foul, stale, and musty odors. Evidence: During the walk through of the physical plant accompanied by the Administrator a foul odor was noticed in the room for resident #5.
Plan of Correction:	FACILITY'S RESPONSE: "Facility will ensure that all buildings are free from foul, stale, and musty odors. Response: ED and RCD will identify any room that requires additional housekeeping to ensure that the room is free from foul, stale, and musty odors. Maintenance Director will audit such identified rooms daily for 2 weeks to ensure rooms are free from foul, stale, and musty odors."