VIRGINIA DEPARTMENT OF SOCIAL SERVICES

COMMONWEALTH SENIOR LIVING AT HAMPTON
1030 TOPPING LANE
Hampton, VA 23666
(757) 826-3728

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: Feb. 21, 2023 , Feb. 24, 2023 and March 10, 2023

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 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 unannounced renewal inspection conducted on 2-21-23 with two licensing inspectors from the Peninsula Licensing Office (Ar. 08:00- dep 19:45) The census on day 1 was 81. A tour of the facility was conducted, medication pass observation conducted, breakfast meal on the safe, secure unit observed, resident interviews and records reviewed, staff interviews and records reviewed. Day 2 ? one inspector from PLO- (ar 09:45 /dep 11:45) a check of the first aid kits in the facility and vehicle conducted, water temperatures checked and signaling checked with maintenance. An exit meeting was conducted on day 1 with the administrator and team. An exit was conducted with the Administrator?s Assistant and the Resident Care Director. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The final exit meeting will be scheduled. 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 #:	22VAC40-73-1110-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure whenever warranted by a change in a resident?s condition, the licensee, administrator, or designee shall also perform a review of the appropriateness of continued placement in the unit. Evidence: 1. On 2-21-23, resident #1 was observed receiving service outside of the safe, secure unit. The record document resident was admitted to the facility?s safe, secure unit (scu) at admission to the facility (10-16-20). Resident was observed outside the unit during medication pass with staff #5. The record documented resident relocated to the assisted living, non-secure unit on 10-1-21. The record did not have documentation of a reassessment to determine to relocation/change in need. 2. Staff #1 acknowledged the resident?s relocation and provided the financial statement showing the relocation but no assessment by the facility.
Plan of Correction:	What Has Been Done to Correct? Documentation was added to resident?s electronic record. How Will Recurrence Be Prevented? All resident records will be stored electronically for safe keeping. Person Responsible: ED, RCD, and or Designee Due Date: 04/01/2023
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure in accordance with 63.2-1805 D Code of Virginia, it did not admit or retain individuals with any prohibitive conditions with required documentation for five of ten records. Evidence: 1. On 2-21-23, resident #1?s record documented resident administered Buspirone. The record did not include a psychotropic treatment plan for this medication. 2. Resident #2?s February 2023 medication administration record (MAR) documented resident prescribed Lorazepam tablets (original date 10-19-22); Lorazepam Intensol (original date 9-17-22) and Seroquel (original date 4-20-22). The record did not include a psychotropic treatment plan for these medications. 3. Resident #5?s February 2023 MAR documented resident prescribed Seroquel (original date 8-13-23). Lorazepam prescribed (original date 8-11-21) on May 2022 physician?s orders. The record did not include a psychotropic treatment plan for these medications. Based on record reviewed and staff interviewed, the facility failed to ensure in accordance with 63.2-1805 D Code of Virginia, it did not admit or retain individuals with any prohibitive conditions with required documentation for five of ten records. Evidence: 1. On 2-21-23, resident #1?s record documented resident administered Buspirone. The record did not include a psychotropic treatment plan for this medication. 2. Resident #2?s February 2023 medication administration record (MAR) documented resident prescribed Lorazepam tablets (original date 10-19-22); Lorazepam Intensol (original date 9-17-22) and Seroquel (original date 4-20-22). The record did not include a psychotropic treatment plan for these medications. 3. Resident #5?s February 2023 MAR documented resident prescribed Seroquel (original date 8-13-23). Lorazepam prescribed (original date 8-11-21) on May 2022 physician?s orders. The record did not include a psychotropic treatment plan for these medications. 4. Resident #6?s February 2023 MAR documented resident prescribed Haloperidol (original date 4-13-21). The record did not include a psychotropic treatment plan for this medication. 5. Resident #10?s record documented resident administered Lorazepam and Seroquel. The record did not include a psychotropic treatment plan for these medications.
Plan of Correction:	What Has Been Done to Correct? Psychotropic treatment plans have been added or updated in resident records. How Will Recurrence Be Prevented? Treatment plans will be reviewed by RCD and PCP per policy. Person Responsible: ED, AED, and or Designee Due Date: 05/01/2023
Standard #:	22VAC40-73-380-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s personal and social data form was kept updated for two of ten records. Evidence: 1. On 2-21-23, resident #1?s individualized service plan (ISP) noted resident allergic to Aspirin, Duloxetine, Meloxicam, Naproxen and Simvastatin. The record also included a document from the local pharmacy and signed by the physician on 1-4-23 documenting resident allergy to Zocor. The resident?s personal and social data form was not updated to include these allergies. 2. Resident #9, the facility?s ?Allergy? form documented resident?s allergy to Raglan, PPD vaccine, Succinylcholine and food allergy to Chromium. The resident?s personal and social data form and ISP 1-12-23 was not updated to include these allergies.
Plan of Correction:	What Has Been Done to Correct? Any updates to resident personal social data will be updated electronically. How Will Recurrence Be Prevented? ED, RCD and or Designee will verify information is up to date during care plan meeting. Person Responsible: ED, RCD, and or Designee Due Date: 04/01/2023
Standard #:	22VAC40-73-440-K
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure for private pay the requirements for the uniform assessment instrument (UAI) was in compliance for three of ten records reviewed. Evidence: 1. On 2-21-23, resident #1?s uniform assessment instrument (UAI) dated 12-1-21, was no signed by the administrator or administrator?s designee of the facility. 2. Resident #2?s UAI dated 11-7-22 was not signed by the administrator or designee of the facility, when the assessor is a facility staff member. The assessment was completed by staff #4. 3. Resident #7?s UAI dated 10-17-22 was not signed by the administrator or designee of the facility, when the assessor is a facility staff member. The assessment was completed by staff #2.
Plan of Correction:	What Has Been Done to Correct? Missing signature was added to completed UAI How Will Recurrence Be Prevented? ED, RCD, and or Designee will ensure all required signatures prior to filling. Person Responsible: ED, RCD, and or Designee Due Date: 04/01/2023
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition for five of ten records. Evidence: 1. On 2-21-23, resident #2?s uniformed assessment instrument (UAI) dated 11-7-22 documented eating/feed need assessed as no help needed. The ISP dated 11-15-22 documented resident, ?must be fed by mouth by another person?requires cutting up of food, opening cartons/packages. Resident has a hospital bed with bed rails on both sides and mats on floor were observed during medication pass with staff #5. These items were not on the resident?s ISP dated 11-15-22. The resident?s date of admission was documented as 10-16-20. 2. Resident #5?s UAI dated 12-31-22 documented bathing assessed as supervision. The ISP dated 1-1-23 documented resident?s need for shower chair/stool. Toileting assessed as no help; bowel and bladder assessed as no help. The ISP documented resident use of adult briefs. Staff #3 confirmed resident use of adult briefs. Resident?s clinical notes documented resident receives podiatry services (5-25-22 and 9-15-22. These services were not documented on the ISP. Resident #5?s ISP dated 9-20-22 and 1-1-23 was not updated to reflect the resident?s non-weight bearing status. The resident?s physician?s clinical notes dated 12-19-22 documented the resident is ?unable to bear weight to bilateral lower extremities for longer period?. According to documentation, the facility nursing staff requested resident be ?accessed for wheelchair accessibility for safety and due to cognitive decline?. The resident?s clinical notes also documented on 1-23-23, the resident received a left knee brace to wear. The resident?s uniformed assessment instrument (UAI) dated 12-31-22 documented resident needed no help transferring, the ISP documented resident require assistance with transfer gait belt to be used with all transfers during evacuation. Mobility, stairclimbing and walking need assessed as no help. The resident was observed using a wheelchair on 2-21-23. The ISP documented resident, ?able to climb stairs with /without assistance; able to walk on different turf without assistance; need assistance for stepping into a vehicle; Independent with mobility/ambulation. Resident?s date of admission was documented as 5-5-21. 3. Resident #6?s UAI dated 12-6-22 documented resident needs no help for activities of daily living (ADLs). The ISP dated 12-23-22 documented bathing staff required to, ?verify bench available and used during bathing., shower bench available and used during showers?. Toileting documented results use of ?adult briefs?; bowel and bladder documented as no help needed. Transferring documented, ?use of grab bars/chair arms for support?. Wandering assessed on UAI, this need not documented on the ISP. Aggressive behaviors not documented on the UAI, the ISP documented resident is, ?disruptive-aggressive-socially inappropriate behavior-verbally and physically; require special tolerance or staff training?. Resident?s date of admission documented as 11-13-20. 4. Resident #7?s social data documented resident is an ?organ donor?. This information was not documented on the resident?s ISP dated 11-14-22. Resident?s date of admission dated as 2-28-18. 5. Resident #9?s ISP dated 2-9-23 did not include all allergies noted on facility Allergy document. Resident?s UAI dated 2-5-23 documented resident is continent of bowel/bladder. The ISP documented toileting need resident, ?use adult pull-up/protective underwear?. The resident?s diet documented on the ISP is ?renal diet?. The facility does not provide this type of diet, per the dietary staff and the facility?s nutrition report dated,11-21-22.
Plan of Correction:	What Has Been Done to Correct? Individualized service plan will be updated for any significant change of resident?s condition. How Will Recurrence Be Prevented? ED and RCD will verify all significant changes have been document. Person Responsible: ED, RCD, and or Designee Due Date: 04/01/2023
Standard #:	22VAC40-73-710-B
Description:	Based on record reviewed, staff interviewed and observation, the facility failed to ensure when physical restraint is used, as a medical/orthopedic restraint for support a written physician?s order and written consent of the resident or legal representative is obtained. Evidence: 1. On 2-21-23, half bed rails were observed on both sides of the resident #2?s hospital bed. The record did not include a written physician?s order for this mechanical device/orthopedic restraint for support.
Plan of Correction:	What Has Been Done to Correct? Written consent will be stored in resident?s electronic record and added to physician?s order sheet. How Will Recurrence Be Prevented? RCD or Designee will review consent with PCP and POA during resident care plan meeting. Person Responsible: ED, RCD, and or Designee Due Date: 04/01/2023
Standard #:	22VAC40-73-870-E
Description:	Based on observation and staff interviewed, the facility failed to ensure all furnishings, fixtures, and equipment shall be kept clean and in good repair and condition. Evidence: 1. On 2-24-23 during a check of the water temperature in residents? room with staff #11. The call bell in room #401 (Buckroe) was coming off the wall and in need of repair. There was no response when pulled. The call bell in the bathroom of room #305 (Langley Hall) and resident?s pendant was checked. There was no response, the occupant of the room stated to the inspector and staff #11, neither system works. 2. The call bell on the male, safe, secure unit, room #503 (Shipyard) was pulled. There was not response, the direct care staff stated ?we don?t use the call bells on this unit, they, referring to the residents, would not know how to use it. 3. The call bell was on the female, safe, secure unit, room #710 (Canon) was pulled. There was no staff response. 4. Staff #11 acknowledged the call bells were not working on the morning of 2-24-23.
Plan of Correction:	What Has Been Done to Correct? All systems have been checked to ensure they are properly working. How Will Recurrence Be Prevented? MD will ensure all call bell are secured firmly during community walk through. Person Responsible: ED, MD, and or Designee Due Date: 05/01/2023