VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at King's Grant House
440 North Lynnhaven Road
Va. beach, VA 23452
(757) 431-8825

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: June 11, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

22VAC40-73-580 22VAC40-73-680

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/11/2024 from 8:48 am to 2:45 pm. 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: 66 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: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 4 residents. The following were reviewed: resident and staff records, medication carts, call bells, and water temperatures. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication. Evidence: 1. The following expired medications were observed in the medication carts at the facility: a bottle of multivitamins expired 11/2022 for Resident #9.
Plan of Correction:	Expired medication was removed from the medication cart and destroyed. Re-educated Executive Director, Resident Care Director, and all Registered Medication Aides on regulation 73-640-A and Policy MP-20 Expired, Damaged or Contaminated Medications.
Standard #:	22VAC40-73-720-A
Description:	Based on record review, the facility failed to ensure a valid written Do Not Resuscitate (DNR) order has been issued by the resident's attending physician; and that the written order is included in the individualized service plan. Evidence: 1. Resident #1 had a DNR order completed 11/28/2023; however, Resident #1?s ISP (dated 12/21/2023) indicated the resident was a full code.
Plan of Correction:	Resident was discharged from community. Audit/comparison of all DNRs to Yardi and residents chart to ensure accurate. Re-educated Executive Director, Resident Care Director, Assistant Resident Care Director, and Wellness Secretary on regulation 73-720-A. Completed DNR form will be collected prior to admission if applicable.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. Staff #5 was hired on 11/28/2023; however, their criminal history record report was completed 06/11/2024. 2. There was not a completed criminal history record reports for Staff #6 (hired 06/20/2023) in their record.
Plan of Correction:	Received and reviewed background checks on Associates #5 and #6. Re-educated Executive Director and Business Office Manager on regulation 90-(BC3)-40-B. An audit of current associate files was performed to ensure compliance with regulations. Moving forward, we will track the new hire background check to ensure it is received and reviewed within 30 days of hire. If not received within 30 days of hire, associate will be removed from the schedule until background check is received.