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: April 1, 2024 and May 2, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/01/2024 (arrival 8:44 am / departure 4:44 pm) and 5/02/2024 (arrival 9:33am / departure 12:30pm). 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 03/21/2024 regarding allegations in the area(s) of: Subsequent complaints were received regarding allegations in the areas of Part III Personnel, Part VI Resident Care and Related Services, and Part VIII Building and Grounds. Number of residents present at the facility at the beginning of the inspection: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 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 allegation(s); area(s) of non-compliance with standard(s) or law were: Part III Personnel and Part VI Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint(s) 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 Darunda Flint, Licensing Inspector at 757-807-9731 or by email at Darunda.a.flint@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-B
Complaint related:	Yes
Description:	Based on a review of staff records the facility failed to ensure that all direct care staff shall attend at least 18 hours of training annually. Direct care staff who are licensed health care professionals or certified nurse aides shall attend at least 12 hours of annual training. Evidence: 1. On 05/02/2024, the record for staff #3 (date of hire:8/07/2019) did not contain documentation of 12 hours of annual training. 2. Staff #7 acknowledged the staff record for staff# 3 did not contain the required amount of annual training.
Plan of Correction:	What Has Been Done to Correct? BOM or designee to monitor employee compliance weekly How Will Recurrence Be Prevented? BOM or designee will monitor employee compliance on a weekly basis to ensure required training hours are met. Person Responsible: BOM
Standard #:	22VAC40-73-210-E
Complaint related:	Yes
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure staff completed training relevant to the population in care and shall be provided by qualified individual through in-service training programs or institutes, workshops, classes, or conferences. Evidence: 1. On 05/02/2024, a review of records for staff #1, staff #2, staff #4, and staff #5 indicated the records did not include documentation of staff training for the population in care. The records did not include documentation of oxygen training and there are residents who are administered oxygen. 2. On 05/02/2024, a review of records for staff #1, staff #4, and staff #5 indicated the records did not include documentation of staff training for the population in care. The records did not include documentation of Hoyer lift training and there are residents who use a Hoyer lift. 3. Staff #12 acknowledged staff did not have the aforementioned training.
Plan of Correction:	What Has Been Done to Correct? Vendors/home health agencies have been contacted to schedule training. How Will Recurrence Be Prevented? BOM and/or designee will ensure training is documented, RCD, ARCD or designee will schedule training to include oxygen training and hoyer lift use for new and current direct care staff. Person Responsible: BOM, RCD, ARCD
Standard #:	22VAC40-73-250-D
Complaint related:	No
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 #1?s date of hire (DOH) was 03/28/2023. The TB assessment was completed on 03/30/2023. 2. Staff #2?s DOH was 2/13/2024. The TB assessment was completed on 02/22/2024.
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 #:	22VAC40-73-290-B
Complaint related:	No
Description:	Based on observation, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. Upon entry on 04/01/2024, the facility current on-site person in charge sign posted was dated for 03/29/2024. 2. Staff #6 acknowledged the facility did not have a current on-site person in charge sign posted.
Plan of Correction:	What Has Been Done to Correct? Posting has been implemented from date of inspection. How Will Recurrence Be Prevented? ED and/or designee will ensure the name of the on-site person in charge is posted at the Concierge desk daily. Person Responsible: ED
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed need of the resident. Evidence: 1. The outside agency form for resident #1 dated 01/15/2024 documented an occupational therapy (OT) evaluation and the frequency was every two weeks. The ISP dated 1/16/2024 did not include the assessed need.
Plan of Correction:	What Has Been Done to Correct? UAI/ISPs identified during inspection have been corrected. 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: RCD, ARCD, RCC and/or designee(s)