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: March 18, 2024 and March 19, 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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 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: 03/18/2024 (arrival 9:11am/departure 7:30 pm) ,03/19/2024 Day 2 (arrival 7:47 am/ departure 5:05 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: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Observations by licensing inspector: Lunch was observed, and an activity was observed. Medication pass observation was completed. The following were reviewed: resident and staff records, medication carts, water temperatures, staff schedule. 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 Darunda Flint, Licensing Inspector at (757)807-9731 or by email at Darunda.a.flint@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-3
Description:	Based on observation and staff interview, the facility failed to ensure infection prevention measures were implemented by staff and volunteers. Evidence: 1.On 03/19/2024, a medication pass observation was conducted with staff #8. Staff#8 administered several medication passes to residents and did not implement infection prevention measures to ensure hand hygiene. 2. Staff #8 acknowledged no hand hygiene practices were implemented.
Plan of Correction:	What Has Been Done to Correct? Medication pass observations have been conducted. How Will Recurrence Be Prevented? Current and new RMAs will be inserviced on proper medication administration procedures to include infection control related to hand hygiene. Med pass observations to be completed for each RMA. Person Responsible: ED, RCD, ARCD
Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents submit the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1.Staff#11?s date of hire was 1/23/24. The TB assessment was completed on 1/25/2024.
Plan of Correction:	What Has Been Done to Correct? TB screenings have been completed prior to the first day of work. How Will Recurrence Be Prevented? Business Office Manager and/or designee will ensure TB screenings are completed during the new hire process within seven days prior to the first day of work. Person Responsible: BOM, ED
Standard #:	22VAC40-73-260-C
Description:	Based on observation and staff interviewed, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR was kept current. Evidence: 1. On 03/19/2024, there was no posting of staff who held first aid and CPR certification. 2. Staff #9 acknowledged there was no posting in the facility.
Plan of Correction:	What Has Been Done to Correct? Current listing has been placed in designated areas. How Will Recurrence Be Prevented? Business Office Manager or designee will monitor postings weekly to ensure they are kept current. Person Responsible: BOM, ED
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) include all assessment needs. Evidence: 1.Resident #2?s Uniformed Assessment Instrument (UAI) dated 09/14/2023 documented bathing as human help only. The ISP dated 09/14/2023 documented bathing human help and mechanical assistance. Dressing assessed as no help; the ISP noted human help physical assist. Toileting assessed as no help; the ISP noted mechanical help. Transferring assessed as no help; the ISP noted hands on assist with transfers. 2.Resident #3?s UAI dated 01/17/2024 documented bowel and bladder needs no help, the ISP dated 1/17/2024 documented toileting adult pull-up /protective under wear. 3.Resident #6?s UAI dated 09/19/2023 assessed bathing human help/physical assist, the ISP dated 9/24/2023 noted mechanical and human help. Walking assessed human help/supervision, the ISP noted human help/supervision and mechanical. 4.Resident#10?s UAI dated 10/14/2023 assessed bathing human help physical assistance, the ISP dated 11/16/2023 indicated a shower chair. The 02/20/2024 and 08/31/2023 Medi health notes indicated the resident had wound care. The Medi Health services are not documented on the residents ISP. 5.Resident#8?s UAI dated 12/19/2023 documented the resident?s psycho-social behavior pattern as appropriate. The ISP dated 01/21/2024 document the resident?s psychosocial history as occasional aggressive or socially inappropriate behavior.
Plan of Correction:	Correct? Corrections have been made to UAI/ISPs identified during inspection. How Will Recurrence Be Prevented? Current UAIs and ISPs will be audited to ensure assessed needs are included on both the assessment and ISP. Person Responsible: ED, ARCD, RCD
Standard #:	22VAC40-73-450-E
Description:	Based on the record reviewed and staff interviewed, the facility failed to ensure the individualized plan (ISP) was signed and dated by the license, administrator, or his designee (the person who had developed the plan), and the resident or his legal representative. The requirements shall also apply to reviews and updates of the plan. Evidence 1.On 3/18/2024, resident #6?s ISP dated 09/24/2023 was not signed by the resident and/or legal representative. 2.Staff #10 acknowledged the residents? ISP was not signed and dated by the resident and/or legal representative.
Plan of Correction:	What Has Bee Signatures have been obtained for ISPs identified during inspection. n Done to Correct? How Will Recurrence Be Prevented? Current ISPs will be audited to ensure the plans have been signed by all parties as required. Person Responsible: ED, ARCD, RCD
Standard #:	22VAC40-73-520-I
Description:	Based on observation and staff interviewed, the facility failed to ensure the activity noted on the schedule was provided. Evidence On 03/18/2024, the activity calendar posted noted, Candy Bingo scheduled for 10:15 am. The activity provided was cornhole. The substitution was not updated on the activity calendar.
Plan of Correction:	What Has Been Done to Correct? Any changes to the activity calendar have been noted How Will Recurrence Be Prevented? Program Director and/or designee will review calendar daily and ensure any changes are noted and residents are made aware. Person Responsible: Program Director, ED
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation the facility failed to ensure medications shall be stored in a manner consistent with the current standards of practice and the storage area shall be locked. Evidence: 1.On 03/19/2024, during the medication pass observation in the safe secure unit with staff #8. Staff #8 left the medication cart unattended and unlocked while administering medication to a resident on the other side of the resident dining room. The medication cart was not visible from the other side of the dining room. 2.Staff #8 acknowledged that the medication cart was left unlocked and unattended.
Plan of Correction:	What Has Been Done to Correct? Each medication cart has been audited to ensure medications are stored properly. How Will Recurrence Be Prevented? Current RMAs will be inserviced on proper medication administration practices as related to maintaining security of med cart at all times. Person Responsible: RCD, ARCD, ED
Standard #:	22VAC40-73-660-A-7
Description:	Based on observation and staff interviewed, the facility failed to ensure that it complied with blood glucose monitoring practices. Evidence: 1.On 03/18/2024, a medication cart observation was conducted with staff #7. Resident #8 and resident #9?s glucometer instrument was not labeled. 2.Staff #7 acknowledged the aforementioned resident glucometers were not labeled.
Plan of Correction:	What Has Been Done to Correct? Current resident glucometers have been audited and both pouch and meter labeled with resident name. How Will Recurrence Be Prevented? Weekly med cart audits will be performed by RMAs, ARCD and RCC. Person Responsible: RCD, ARCD, ED
Standard #:	22VAC40-73-860-G
Description:	Based on observation and staff interviewed, the facility failed to ensure the hot water at taps available to resident shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F. Evidence: 1.On 03/18/2024, during a tour of the facility with staff #4 the hot water temperature was checked in room #610 and the reading was 123 F, room #604 and the reading was 120.5 F, and room #503 and the reading was 120.6 F. 2.Staff #4 acknowledged the water temperature was not within the required temperature range.
Plan of Correction:	What Has Been Done to Correct? Water temperatures adjusted for rooms identified as out of range. How Will Recurrence Be Prevented? Maintenance Director and/or designee will test water temperatures weekly on each wing/hallway and alternating rooms. Person Responsible: Maintenance Director, ED
Standard #:	22VAC40-73-860-I
Description:	Based on observation and staff interviewed, the facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area. Evidence: 1.On 03/18/2024, during a tour of the facility with staff #9 cleaning supplies, hazardous chemicals, and an electric power tool were being stored outside on the porch in the resident courtyard. 2. Staff #9 acknowledged the cleaning supplies, hazardous materials, and an electric power tool were being stored outside on the porch in the resident courtyard.
Plan of Correction:	What Has Been Done to Correct? Cleaning supplies have been secured/stored in a locked area. How Will Recurrence Be Prevented? Staff are responsible for use of cleaning supplies and/or any tools will be inserviced on proper storage. Person Responsible: ED, Maintenance Director
Standard #:	22VAC40-73-870-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. Evidence 1.During a tour of the facility on 3/18/2024, the assisted living unit resident courtyard had a wooden pallet propped against the exterior wall of the building, a wooden plank laying on the ground, and potholes in the lawn. 2.The blinds in the room of resident #1 had broken slats. 3.Staff #9 acknowledged the aforementioned.
Plan of Correction:	What Has Been Done to Correct? Building interior and exterior has been inspected for repair needs. How Will Recurrence Be Prevented? Maintenance Director and/or designee will make daily rounds of building exterior. Maintenance Director and/or designee(s) will inservice housekeeping staff on inspecting and reporting any needs for repair in resident rooms and/or common areas. Person Responsible: Maintenance Director, Executive Director
Standard #:	22VAC40-73-930-A
Description:	Based on observation and staff interview, the facility failed to ensure that a signaling device is easily accessible to the resident in his bedroom or in a connecting bathroom that alerts the direct care staff that the resident needs assistance. Evidence: 1.On 03/18/2024, during a tour of the facility the call bells were pulled in serval residents? rooms, but no staff responded. Staff #4 acknowledged that the call system was not working.
Plan of Correction:	What Has Been Done to Correct? Call system repaired and proper function restored on 3/22/2024. How Will Recurrence Be Prevented? ED, Maintenance Director and/or designee(s) will monitor call system daily to ensure system is functioning properly. Person Responsible: ED, Maintenance Director
Standard #:	22VAC40-73-950-E
Description:	Based on onsite review, the facility failed to ensure a semi-annual review of the emergency preparedness and response plan with staff, residents, and volunteers. Evidence: 1. On 03/18/2024 , the most recent semi-annual review of emergency preparedness and response plan with staff was last reviewed on 08/22/2023. 2. There was no documentation to support semi-annual reviews of the emergency preparedness and response plan with residents and volunteers/other were being reviewed. 3.Staff confirmed the most recent semi-annual review of emergency preparedness and response plan with staff was last review on 08/22/2024, and there was no documentation of semi-annual review of emergency preparedness and response plan with resident and volunteers/other.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-990-C
Description:	Based on onsite review, the facility failed to ensure at least every six months, all staff currently on duty on each shift participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years. Evidence: 1.On 03/18/2024, the facility documentation of an exercise in which the procedures for resident emergencies were practiced last dated 07/11/2023. 2.Staff confirmed the most recent exercise in which the procedures for resident emergencies were last practiced on 7/11/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.