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: March 5, 2024 and March 6, 2024

Complaint Related: No

Areas Reviewed:

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 63.2 PROTECTION OF ADULTS AND REPORTING 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal An on-site renewal inspection was conducted on 3-5-24 (Ar 08:35 a.m./dep 17:50 p.m.) and 3-6-24 (Ar 09:30 a.m./dep 1:10 p.m.). The census on 3-5-24 was 57. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on observation and staff interviewed, the facility failed to ensure the blood glucose monitoring practices were consistent with CDC recommendations. Evidence: 1. On 3-5-24 during the medication pass observed in the safe, secure unit with staff #3, resident #6?s glucometer was observed to not have a label. 2. Staff #3 acknowledged the resident?s glucometer was not labeled.
Plan of Correction:	What Has Been Done to Correct? Label with Resident?s name was added to the blood glucose case. How Will Recurrence Be Prevented? During monthly cart audits blood glucose equipment will be checked to ensure proper labeling. Person Responsible: ED, AED, and RCD, RCC or designee Due Date: 4/1/2024 and ongoing
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs. Evidence: 1. On 3-5-24, resident #1?s uniformed assessment instrument (UAI) dated 2-12-24 noted bathing need as mechanical help/human help/supervision. Toileting and transferring need assessed as mechanical help. The individualized service plan (ISP)completed by staff #8 dated 2-15-24 did not include the mechanical help device. Walking assessed as mechanical help/human help/supervision. Stairclimbing assessed as mechanical help/human help/supervision. The ISP did not include the mechanical device. 2. Staff #2 acknowledged the resident?s ISP did not include all assessed needs or match with assessment documentation.
Plan of Correction:	What Has Been Done to Correct? An audit will be conducted to compare the UAI to the ISP and adjustments will be made where needed. How Will Recurrence Be Prevented? The RCD, ED, or Designee will review the UAI and ISP for congruence prior to implementation. Person Responsible: ED, RCD, or Designee Due Date: Starting April 1, 2024 with a completion date of April 19, 2024 for those files reviewed during the inspection and ongoing
Standard #:	22VAC40-73-450-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the resident and or the legal representative for three of five resident?s record. Evidence: 1. On 3-5-24, resident #3?s individualized service plan (ISP) dated 1-19-24 was not signed by the resident or the resident?s legal representative. 2. Resident #4?s ISP dated 1-22-24 was not signed by the resident or the resident's legal representative. 3. Resident #5?s ISP dated 1-25-24 was not signed by the resident or the resident's legal representative. 4. Staff #2 acknowledged the aforementioned resident?s ISP was not signed by the resident or the resident's legal representative
Plan of Correction:	What Has Been Done to Correct An appointment will be made with the three (3) residents and their responsible parties to review, sign and date the ISP. How Will Recurrence Be Prevented? When ISPs are created/ updated, the resident and responsible party will be notified. The RCD, RCC or Designee will request that they review the ISP, sign and date. Person Responsible: RCD, RCC, or designee Due Date: April 19, 2024
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition included all assessed needs. Evidence: 1. Resident #2?s record included multiple dates of skilled nursing services for wound care from 12-1-23 to 1-18-24 for sacrum, left calf, and right elbow. This service was not noted on the resident?s ISP. The resident?s UAI dated 1-24-24 and ISP dated 2-10-24 noted stairclimbing as mechanical help/human help/physical assistance. The ISP completed by staff #8 and dated 2-10-24 did not include who would provide service and when and where. According to staff #2, the resident is not able to walk and physically not able to climb stairs. The resident?s provider?s medical progress noted the resident has a pacemaker. These services were noted included on the resident?s ISP. 2. Resident #3?s UAI dated 1-19-24 noted transferring assessed as mechanical help/human help/supervision. The ISP completed by staff #8 and dated 1-19-24 resident ?required assistance with transfer and or positioning with verbal prompts/cues, no hands on assistance needed?. The need did not identify the mechanical help needed. 3. Resident #4?s UAI dated 1-22-24 noted bathing need assessed as mechanical help/human help/physical assistance (mh/hh/pa) The ISP completed by staff #8 and dated 1-22-24 noted resident, ?can bath without physical assistance but may require reminding or standby assistance. Verify bench is available?grab bar is available and verify hand held shower is available?. Dressing need assessed as mh/hh/pa. The ISP noted resident, ?can dress undress and select clothing but may need to be reminded/supervised. Toileting need assessed mh/hh/pa. The ISP noted resident, ?requires standby assistance for toileting task?uses adult pull up, and grab bars??. Stair climbing need assessed mh/hh/pa. The ISP noted resident, ?may utilize the hand rails?for safe ambulation.? 4. Resident #5?s UAI dated 1-23-24 noted transferring needs assessed as mechanical help/human help/physical assistance. The ISP completed by staff #8 and dated 1-25-24 noted resident, ?may use arms of the furniture during transfers?arm rest/handrails in hallways for ambulation as needed. Staff #2?s and inspector went to the safe, secure unit to determine resident?s ability to transfer, walk, climb stairs. Staff on the safe, secure, unit stated using a Hoyer Lift to assist resident #2 with transferring. Resident does not walk, stand due to wounds on legs and not able to climb stairs. The UAI noted walking, wheeling, stairclimbing, and mobility assessed as mechanical help/human help/physical assistance. The ISP noted resident, ?climb stairs, without assistance handrails needed?highback wheelchair, calf protector and footrest use with ambulation devices?dependent upon staff for all mobility/ambulation needs. Stairclimbing need did not include who would provide the services and when and where. 5. Staff #2 acknowledged the residents? assessments and ISPs did not agree/match the assessment.
Plan of Correction:	What Has Been Done to Correct? An audit will be conducted to ensure that the ISP has been updated in the last 12 months and reflects any changes of condition. How Will Recurrence Be Prevented? The RCD/ RCC or Designee will review the UAI and ISP for congruence prior to implementation. Person Responsible: RCD, RCC, or Designee Due Date: Starting April 1, 2024 with a completion date of April 19, 2024 and ongoing
Standard #:	22VAC40-73-720-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the written order for a Do Not Resuscitate (DNR) was included on the individualized service plan (ISP). Evidence: 1. On 3-5-24, resident #2?s record included a written DNR signed and dated 5-30-17. The resident?s ISP dated 2-10-24, page 3, Demographics noted the resident is a ?Full Code- CPR will be performed by certified staff in the event of cardiac/respiratory arrest?. 2. Staff #2 acknowledged the aforementioned resident?s ISP did not include the resident?s written DNR.
Plan of Correction:	What Has Been Done to Correct? An audit will be conducted to ensure that Code Status is properly noted on the ISP. How Will Recurrence Be Prevented? The RCD/ RCC or Designee will ensure that code status is annotated on the ISP at admission and with any change of condition. Person Responsible: RCD, ED, or Designee Due Date: Starting April 1, 2024 with a completion date of April 19, 2024 for those files reviewed during the inspection and ongoing
Standard #:	22VAC40-73-980-A
Description:	Based on observations and staff interviewed, the facility failed to ensure the first aid kits in the facility included all required items. Evidence: 1. On 3-5-24, the first aid kit on the safe, secure unit was checked with staff #3 did not include band-aid in assorted sizes, gauze pads and roller gauze in assorted sizes. Staff #3 acknowledged the first aid kit did not include all required items. 2. On 3-6-24, the first aid kit on the second floor did not include the disposable single-use breathing barriers or shields for use with rescue breathing or CPR. Staff #9 acknowledged the first aid kit on the second floor did not have all required items.
Plan of Correction:	What Has Been Done to Correct? Assorted band aids and breathing barriers have been added to the first aid kits. How Will Recurrence Be Prevented? A monthly audit of first aid kits will be conducted and any missing or needed items will be procured. Person Responsible: RCD / Maintenance Director or Designee Due Date: March 31,2024