VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living At Charlottesville
1550 Pantops Mountain Place
Charlottesville, VA 22911
(434) 977-4094

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: April 11, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An onsite monitoring inspection was conducted by LI Poulter on 10/11/23. An onsite inspection was conducted by LI Stevenson and LI Randolph on 03/25/24. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 09/13/24 and 09/19/24 regarding allegations in the area(s) of: Personnel, staffing and supervision, and resident care and related services. Number of resident records reviewed: 2 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 Coy Stevenson, Licensing Inspector at 804-972-4700 or by email at coy.stevenson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-110-1
Description:	Based on a review of documentation, it was determined that the facility did not ensure that all staff shall be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled. Evidence: 1) On September 19, 2023, staff #2 was involved a verbal incident with resident #3. 2) In interview notes provided by the facility, staff #2 admitted to using profanity and derogatory language towards resident #3.
Plan of Correction:	What Has Been Done to Correct? Staff #2 was in-service on proper conduct and caring for residents in the community. Staff #2 has also been separated from the community and the CSL organization. How Will Recurrence Be Prevented? Community will conduct an in-service, train, and re-train associate on code of conduct per CSL- Company policy. Person Responsible: Executive Director and Business Office Manager
Standard #:	22VAC40-73-680-D
Description:	Based on a review of the two records, it was determined that facility staff did not administer medications in accordance with the physician's or other prescriber?s instructions. Evidence: 1) On September 07, 2023, staff #1 gave resident #1 medication that was not prescribed. The medication given to resident #1 was prescribed for resident #2. 2) The facility made self-report that noted resident #1 was administered incorrect medication.
Plan of Correction:	What Has Been Done to Correct? Missed medication audit by community and Pharmacy. Also review "missed meds" each day, to address in real time and coach staff on proper documentations. How Will Recurrence Be Prevented? Medication oversight by Community and Pharmacy. Daily crossover medication cart audit and count, from the prior shift med tech. Person Responsible: Executive Director and Resident Care Director
Standard #:	22VAC40-73-680-I
Description:	Based on a review of documentation, it was determined that the provider did not document on the Medication Administration Record (MAR) any medications that occur. Evidence: 1) The medication administration record (MAR) for resident #1 did not note a medication error occurred on September 07, 2023. 2) The facility made self-report that noted resident #1 was administered incorrect medication.
Plan of Correction:	What Has Been Done to Correct? MAR review by community and Pharmacy also, in-service with med techs on proper documentation and reporting. How Will Recurrence Be Prevented? Medication oversight by Community and Pharmacy. Daily crossover medication cart audit and count, from the prior shift med tech. Person Responsible: Executive Director and Resident Care Director.