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: Jan. 31, 2024

Complaint Related: Yes

Areas Reviewed:

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint An on-site unannounced complaint inspection was conducted on 1-31-24. (AR- 11:22 a.m./Dep 17:35 p.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 1-10-24 regarding allegations inn the area of admissions and retention, 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: 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 valid 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-A
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that the resident?s admitting physical did not include any of the conditions or care needs prohibited by 22VAC40-73-310-H. Evidence: 1. On 1-31-24, resident #1?s physical examination document dated 10-16-23 documented the resident ?required continuous licensed nursing care?. 2. Staff #1 acknowledged the resident?s admitting physical examination noted resident?s need for continuous licensed nursing care.
Plan of Correction:	What Has Been Done to Correct? Resident was discharged on 02/02/2024. How Will Recurrence Be Prevented? The Report of Physical Examination will be reviewed, prior to admission, to assure it does not include any conditions or care needs prohibited by regulatory standard. Current resident files, for residents residing in community from 1/31/2024 to present, will be audited to assure the Report of Physical Examination does not include prohibited conditions or care needs, per regulatory standards. Person Responsible: ED, AED, RCD or designee Due Date: 5.19.2024 and ongoing
Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the fall risk rating was reviewed and updated after a fall. Evidence: 1. On 1-31-24, resident #1?s progress notes on 11-01-23 at 12:06 a.m. by staff #5 documented, resident wandered to the 3rd floor, another resident heard the resident yelling for help and call the concierge. The concierge found resident #1 laying in the hallway and confused, complained of knee pain, and stated hitting head; resident sent out via ambulance to the ER. Progress note dated 12-13-23 at 2:39 p.m. by staff #3 documented resident had a fall in resident?s apartment. A physician communication document dated 12-25-23 completed by staff #4 documented resident?s fall on 12-12-23. Progress notes dated 12-24-23 at 2:54 p.m. by staff #4 documented resident ?was found laying on the floor?. Resident stated, ?falling while walking to the bed.? 2. On 1-31-24, staff #3 acknowledged the resident?s fall risk review was not completed following each fall.
Plan of Correction:	What Has Been Done to Correct? Resident was discharged on 02/02/2024. How Will Recurrence Be Prevented? A fall risk rating will be completed on each resident subsequent to each fall. An audit will be conducted for resident incidents involving falls from 1.31.2024 to present. Person Responsible: ED, AED, RCD, RCC, RMA or designee Due Date: 5.19.2024 and ongoing
Standard #:	22VAC40-73-450-A
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the preliminary plan was signed and dated by the licensee, administrator, or designee (the person who has developed the plan) and by the resident or resident?s legal representative. Evidence: 1. On 1-31-24, during a complaint inspection, resident #1?s preliminary plan of care dated 10-12-23 developed by staff #3, was not signed and dated by the resident or resident?s legal representative. 2. On 1-31-24, staff #1 and #3 acknowledged, the resident?s preliminary plan was not signed and dated by the resident or resident?s legal representative.
Plan of Correction:	What Has Been Done to Correct? Resident was discharged on 02/02/2024. How Will Recurrence Be Prevented? An initial care plan will be developed for all residents within 7 days of admission or on the day of admission. The care plan will be signed and dated by the administrator or designee as well as the resident or their legal representative. An audit will be conducted of resident care plans from 1.31.2024 to present. Person Responsible: ED, AED, RCD, RCC or designee Due Date: 5.19.2024 and ongoing
Standard #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the comprehensive individualized service plan (ISP) was completed within 30 days after admission. Evidence: 1. On 1-31-23, during a complaint inspection, resident #1?s individualized service plan (ISP) was developed by staff #3 on 1-19-24 and was not signed or dated by the developer or anyone who contributed to the development. The resident?s progress note document completed by staff #3 on 12-26-23 at 3:35 p.m. documented the resident was transported to a local hospital and did not return to the facility. Resident #1?s date of admission was noted as 10-30-23. 2. Staff #1 acknowledged the resident?s comprehensive ISP was not completed within 30 days of admission and after the resident was no longer in the facility.
Plan of Correction:	What Has Been Done to Correct? Resident was discharged on 02/02/2024. How Will Recurrence Be Prevented? A comprehensive care plan will be developed for all residents within 30 days of admission. The care plan will be signed and dated by the administrator or designee as well as the resident or their legal representative. An audit will be conducted of resident care plans from 1.31.2024 to present. Person Responsible: ED, AED, RCD, RCC, RMA or designee Due Date: 5.19.2024 and ongoing
Standard #:	22VAC40-73-650-A
Complaint related:	Yes
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician, or other prescriber. Evidence: 1. On 1-31-24, during a complaint inspection, resident #1?s October and November 2023 medication administration record (MAR) documented resident?s ?Metformin 500mg take one tablet by mouth twice daily for Diabetes Mellitus II? was discontinued. The record did not include documentation of a signed and dated physician?s order to discontinue Metformin 500mg twice a day. 2. On 1-31-24, staff #3 acknowledged the resident?s record did not include a discontinued order for Metformin twice a day.
Plan of Correction:	What Has Been Done to Correct? Resident was discharged on 02/02/2024. How Will Recurrence Be Prevented? Resident medication, dietary supplement, diet, medical procedure, or treatment shall not be started, changed, or discontinued by the facility without a valid order from a physician. An audit will be conducted to review resident charts for valid physician?s orders 1.31.2024 to present. Person Responsible: ED, AED, RCD, RCC, RMA or designee Due Date: 5.19.2024
Standard #:	22VAC40-73-680-K
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure medication ordered for as needed (PRN) included symptoms that indicated the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist. Evidence: 1. On 1-31-24, resident #1?s October, November, and December 2023 medication administration record (MAR) noted ?Acetaminophen tablet 325mg take one tablet every 4-6 hours as needed for pain?. The physician order sheet (POS) signed and dated 11-30-23 by the resident?s physician documented ?Acetaminophen take on tablet by mouth- every 4-6 hours as needed for pain?. 2. Staff #1 and #3 acknowledged the resident?s PRN Tylenol did not document the exact dosage.
Plan of Correction:	What Has Been Done to Correct? Resident was discharged on 02/02/2024. How Will Recurrence Be Prevented? Resident medication ordered for as needed (PRN) will include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24- hour period, and directions as to what to do if symptoms persist. An audit will be conducted of PRN medications 1.31.2024 to present. Person Responsible: ED, AED, RCD, RCC, RMA or designee Due Date: 5.19.2024 and ongoing