VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Kilmarnock
460 S. Main Street
Kilmarnock, VA 22482
(804) 435-9896

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: Aug. 27, 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 ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 622VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 3.2 PROTECTION OF ADULTS AND REPORTING

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: 08/27/2024 11:00am to 3:45pm 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: 59 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Lunch, weekly menu and resident activities were observed. A medication pass observation was completed. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Inspector observed residents enjoying their lunch in the dining room as well as sitting on the patio outside of the facility. Additional Comments/Discussion: 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.Haskins@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1100-C
Description:	Based on a review of resident records, it was determined that the facility did not ensure that the facility shall document that the order of priority specified in subsection A of this section was followed, and the documentation shall be retained in the resident?s file. Evidence: 1. The Order of Priority list contained in the record for resident #5 only had the physician?s signature, and no indication was documented as to why approval was not completed by the resident, a guardian or a relative. 2. Staff #5 reviewed the record for resident #5, and was unable to provide documentation during the onsite inspection that the Order of Priority was followed and documented.
Plan of Correction:	Resident #5 Approval for placement in special care was updated to reflect the order of priority specified in subsection A of the approval form. The Executive Director and Resident Care Director will complete an audit of current records of those residents that reside in special care unit to ensure the priority specified in subsection A, for the approval form, is appropriately documented to subsection B to meet regulatory requirements. Moving forward, the approval for placement will include an appropriate explanation as to why approval was not received from the relationship listed above. For the next 60 days, the RCD/designee will complete a review of each new approval received to assure appropriate documentation is included.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of resident records and interview, it was determined that the facility did not ensure that individualized service plans shall be reviewed and updated at least once every 12 months and as needed for a significant change of resident?s condition. Evidence: 1. The most recent Individualized Service Plan (ISP) in the record for resident #1 was dated 07/25/2023. 2. The most recent Individualized Service Plan (ISP) in the record for resident #6 was not updated when the resident was placed on hospice on 12/05/2023. 3. Staff #5 reviewed the records for resident #1 and resident #6 and was unable to provide documentation during the onsite inspection that the Individualized Service Plan (ISP) had the annual review for resident #1 and had been updated resident #6.
Plan of Correction:	The individual service plans for resident's #1 and #5 have been updated on 9/6/2024 and reviewed by the residents or their representatives. An audit of current residents ISP's will be completed to assure that each resident has a current ISP updated to meet regulatory standards, and it has been updated with current services. Audit will also assure that the ISP has been signed by all appropriate individuals. Moving forward, the RCD/designee will assure that each resident has an ISP updated at least annually and with change of condition and appropriately signed by resident/responsible party. For the next 60 days, the ED/designee will complete a random review of updated ISP's to assure compliance with regulatory standard.
Standard #:	22VAC40-73-720-A
Description:	Based on a review of resident records and interview, it was determined that the facility did not ensure a valid indication of Do Not Resuscitate Order (DNR) for withholding cardiopulmonary for a resident in the event of cardiac or respiratory arrest in the resident?s Individualized Service Plan (ISP). Evidence: 1. The Individualized Service Plan (ISP) in the record for resident #2 did not include a Do Not Resuscitate (DNR) order. There is a signed doctor?s order indicating Do Not Resuscitate (DNR) in the record for resident #2. 2. Staff #5 reviewed the record for resident #2 , and was unable to provide documentation during the onsite inspection that the Individualized Service Plan (ISP) updated to include the Do Not Resuscitate Order (DNR) order.
Plan of Correction:	An audit of current resident records was completed on 09/13/2024 to ensure that the appropriate code status is documented to the ISP. Audits were completed by the Resident Care Director and their designee. Moving forward the RCD/designee will assure the appropriate code status is included on the ISP.
Standard #:	22VAC40-73-940-A
Description:	Based on a review of documentation and interview, it was determined that the facility did not ensure that an assisted living facility shall comply with the Virginia Statewide Fire Prevention Code (13VA5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: 1. There was no documentation available for viewing during the onsite inspection of a current fire inspection. 2. Staff #6 confirmed that contact has been made with the fire department in which the facility was informed that there is a staffing issue and inspection would be completed, however, a date was not as to when that would be.
Plan of Correction:	An inspection by the Virginia State Fire Marshall was conducted on 09/03/2024. No violations were issued during the inspection. To ensure compliance with the Virginia Statewide Fire Prevention Code, the Maintenance Director will contact the Fire Marshall's office 60 days prior to the date of the next annual fire inspection.
Standard #:	22VAC40-73-970-A
Description:	Based on a review of emergency evacuation drill log and interview, it was determined that fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). Evidence: 1. The last documented emergency evacuation drill was completed on 5/30/24. 2. Staff #4 confirmed that the facility?s last drill took place on 05/30/2024 and prior to this date, the last drill took place during May 2023.
Plan of Correction:	Emergency evacuation and drill were conducted on 8/28/2024 in compliance with the Virginia Statewide Fire Prevention Code. The Maintenance Director/Designee will conduct monthly emergency evacuation drills with participation in compliance with the Virginia Statewide Fire Prevention Code, assuring each shift is completed in a quarter. Documentation including participation will be recorded and submitted to the ED/designee for review. Compliance will be monthly and ongoing.