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: Aug. 29, 2024 and Dec. 3, 2024

Complaint Related: No

Areas Reviewed:

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

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/29/2024 (arrival 10:30 a.m./ departure 5:00 p.m.) 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 08/15/2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 82 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 6 Number of interviews conducted with residents: N/A 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 Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at darunda.a.flint@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-E
Description:	Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian. Evidence: 1. Resident #1?s ISP dated of 02/25/2024 did not include the date and signature of the resident and/or legal representative. 2. Staff #2 acknowledged the aforementioned resident?s ISP was not signed by the resident and/or representative.
Plan of Correction:	POC: All updated ISPs will be discussed with residents POA and signed by all parties involved. Care Plans will be emailed to resident?s POA upon completion and POA called to set up a care plan meeting at that time. Documentation of when it was sent and to whom it was sent to will be included on the new care plan that will be located in the resident?s chart Date To Be Corrected: 08/23/2024-continuing.
Standard #:	22VAC40-73-460-A
Description:	Based on a review of a self-reported incident and staff interviewed the facility failed to assume general responsibility for the health, safety, and well-being of a resident in their care. Evidence: 1.As evidence by interview with staff #2 and record review, it has been determined that the facility failed to assume general responsibility for the wellbeing of residents. Per the incident report completed by staff #1 on 08/15/2024 and the final incident report completed by staff #2 on 08/27/2024, resident #1 was restrained with an unauthorized restraint from approximately 6:30am until 11:15 am on 08/15/2024. 2. On 09/16/2024, the LI received the facilities restraint policy from staff #2. Per the facilities policy ?staff will observe and respect the personal rights of all residents, including being free form physical and chemical restraints?. 3. On 9/17/2024 , the LI interviewed staff #7. Staff #7 acknowledged tying a sheet around resident #1?s body and resident #1?s wheelchair to restrain the resident #1. Resident #1 has an unsteady gait and had gotten out of their wheelchair two times prior that morning before staff #7 restrained resident #1 to the wheelchair. 4. On 9/17/2024 ,the LI interviewed staff #9. Staff #9 acknowledged seeing resident #1 on 8/15/2024 restrained to the wheelchair around 6:00 a.m. that morning.
Plan of Correction:	POC: Staff was re-educated on the policies regarding restraints, incident reports, and resident abuse and neglect Date To Be Corrected: 08/23/2024-continuing.
Standard #:	22VAC40-73-550-C
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure that a resident of an assisted living facility rights were met. Evidence: On 8/15/2024, the licensing inspector received an initial incident self-report from staff #1 which indicated that a report was received by staff that resident #1 was seen sitting in their wheelchair in the dining area with a sheet tied around their abdomen and the wheelchair, resident #1?s right to be treated with courtesy, respect, and consideration as a person of worth, sensitivity, and dignity were ignored by staff #4, staff #5, staff #6, staff #7, staff #8, and staff #9. (63.2-1808 A.11).
Plan of Correction:	POC: During mandatory nursing staff meeting, associates were re-educated on the individual resident rights by going over them one by one. Associates verbally indicated an understanding of the rights to prevent any future incidents. Date To Be Completed: 08/23/2024-continuing All individuals directly involved in the
Standard #:	22VAC40-73-710-B
Description:	Based on record review and interview, the facility failed to ensure physical restraints shall not be used for purposes of discipline or convenience. Physical restraints may only be used as a medical/orthopedic restraint for support, according to a physician?s written order and with the written consent of the resident or his legal representative or in an emergency situation after less intrusive interventions have proven insufficient to prevent imminent threat of death or serious physical injury to the resident or others. Evidence: 1. On 08/15/2024, the licensing inspector (LI) received an initial incident self-report from staff #1 which indicated that a report was received by staff that resident #1 was seen sitting in their wheelchair in the dining area with a sheet tied around the abdomen area of the resident to the wheelchair. 2.On 08/28/2024, the LI received a final incident self-report from staff #2 which indicated that all staff involved with the 08/15/2024 initial incident self-report were no longer employed by the facility. 3. Staff #2 acknowledged there was not a physician?s order to restrain resident #1.
Plan of Correction:	POC: Staff was re-educated on the policies regarding restraints, incident reports, and resident abuse and neglect. Date To Be Corrected: 08/23/2024-Mandatory nursing staff meeting with RCD Specialist.