VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Farnham
511 Cedar Grove Road
Farnham, VA 22460
(804) 394-2102

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Sept. 14, 2021

Complaint Related: Yes

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 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: September 14, 2022 (hybrid inspection) 12:17 p.m. to 4:05 p.m. September 21, 2021, (Onsite inspection)Time: 4:45pm to 6:30pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint as received by VDSS Division of Licensing on (09/13/2021) regarding allegations in the area(s) of: ADMINISTRATION AND ADMINISTRATIVE SERVICES STAFFING AND SUPERVISION RESIDENT CARE AND RELATED SERVICES RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS COMPLAINT INVESTIGATION Number of residents present at the facility at the beginning of the inspection: 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:1 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Observed mechanical assistant devices in use by residents. Staff was accessible and available. Additional Comments/Discussion: N/A 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: 1) 450 E 2) 680 C 3) 560 C 4) 325 B3 5) 680 D 6) 70 A 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 Vashti Colson, Licensing Inspector at (804) 662-9432 or by email at Vashti.Colson@dss.virginia.gov Violation Notice Issued: Yes

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	VIOLATION: Based upon the record review, the facility failed to notify the Central Regional Licensing office within 24 hours of any major incident that would negatively affect or threatens the life, health, safety, or welfare of any resident. EVIDENCE: 1) Based upon the Department?s requests for additional documents on February 18, 2021, to February 23, 2021, the facility provided some of the progress notes/hospice notes for residents 2-10. The facility failed to notify the Central Regional Licensing Office concerning unknown bruises found on resident #2 on 08/08/2021. As per the progress notes dated 08/08/2021, the following was noted, ?Areas were found on resident right leg. Two (2) areas on the front of her leg and one (1) on the lower back of her leg that is black with redness around the area. NP and ARCD were notified of the areas found. ? 2) The facility failed to provide notice to the Central Regional Licensing office concerning resident #6`s wounds for the dated incidents on 9/21/2021, 12/19/2021, and 2/08/2022. As per the progress notes resident #6 displayed indicators of a wound on her right heel, which the progress notes states the following: ?Medical Director and hospice notified. New orders sent to hospice, skin prep and cover wound twice a week. If wound open or drain notify NP. Protective boots (waiting on hospice to send) Q2H rounding and float heels until boots arrive. ? 3) The facility failed to provide notice to the Central Regional Licensing Office of an incident, dated 05/05/2021, concerning resident #3?s wound. As per the progress notes for resident #3, which states the following: ?Resident?s bottom is red in color, and has some yellow drainage. No smell. Hospice nurse came out and changed dressing. No new orders or treatment. Resident is to be turned q2h or PRN. Also, resident need to be kept dry at all times. No pain was stated from resident at time. ??? Risk Rating : B-1
Plan of Correction:	What Has Been Done to Correct: Licensing has been and will continue to be notified in the future of all major incidents that would negatively affect or threatened the life, health, safety or welfare of any resident. How Will Recurrence Be Prevented: Review 24-hour logs by ED and ARCD every morning before stand up and communicate findings to licensing as needed. Person Responsible: Executive Director and Assistant Resident Care Director and communicate findings to licensing as needed.
Standard #:	22VAC40-73-325-B
Complaint related:	Yes
Description:	VIOLATION: Based upon the record review and documents submitted by the facility, the facility failed to update each resident?s fall risk rating after a fall. EVIDENCE: 1) Resident # 1 had several reported falls on the following dates: 06/13/2021, 07/23/2021, and 08/05/2021. Based upon the record review, the facility failed to provide evidence that a fall risk assessment was completed after each identified fall. 2) The documentation in the incident reports and progress notes for resident #8, acknowledged that the resident fell on 06/28/2020. The facility failed to have a fall risk assessment for the identified fall. 3) The documentation in the progress reports for resident # 7, acknowledged two falls on the following dates: 12/16/2021 and 09/24/2021. During the record review, the facility failed to have a risk fall assessment for each identified fall. Risk Rating : B-2
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-E
Complaint related:	Yes
Description:	VIOLATION: Based upon the record review and the documents submitted by the facility, the facility failed to have each individualized service plan signed and dated by the resident or legal representative. EVIDENCE : 1) The individualized service plan dated 1/31/2021, for resident #2 failed to have the resident?s signature or the resident?s legal representatives signature . 2) The individualized service plan dated 05/27/2019, for resident #9 failed to have the administrator, designee, resident, or resident?s designee signature. Risk Rating : B-1
Plan of Correction:	What Has Been Done to Correct: This was during covid. Several POA?s refused to come to the community during this time. How Will Recurrence Be Prevented: We will ensure that meetings are scheduled on the date that the ISP?s are completed. The ISP?s will email to those that are unable to come to the community. Also, a note will be placed on the signature page with the date the ISP?s were emailed and it will be put in the medical charts until the signed copy is available. Person Responsible: Executive Director and Assistant Resident Care Director
Standard #:	22VAC40-73-560-C
Complaint related:	Yes
Description:	VIOLATION: Based upon the record review, the facility failed to maintain all physician?s notes and progress reports in each resident?s record. EVIDENCE: The facility failed to retain and have accessible for the complaint review all hospice progress notes for the following resident records: #4, #5, #6, #7, and #8 Risk Rating : B-1
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-C
Complaint related:	Yes
Description:	VIOLATION: Medication shall be administered not earlier than one hour before and no later than one hour after the facility?s standard dosing schedule , except for those drugs that are ordered for specific time such as before , after , or with meals. EVIDENCE: Based upon the record sample, the following items were administered late to the residents listed below: A) The July and June 2021, medication administration records (MARs) scheduled resident #1 to receive the following medications by 10:00 a.m. The following medication were administered to resident #1 late: 1) July 09, 2021, Potassium Chloride BR 20 MEQ was administered to resident #1 at 11:02 a.m. 2) July 31, 2021, Potassium Chloride BR 20 MEQ was administered to resident #1 at 11:30 a.m. 3) July 15, 2021, Potassium Chloride BR 20 MEQ was administered to resident #1 at 11: 13 a.m. 4) June 19, 2021, Potassium Chloride BR 20 MEQ was administered to resident #1 at 11:26 a.m. 5) July 21, 2021, Vitamin B-12 1000 MCG was administered to resident #1 at 11:30 a.m. 6) July 31, 2021, Multivitamin was administered to resident #1 at 11:30 a.m. 7) June 14, 2021, Sertraline HCL oral 25 tablets MG was administered to resident #1 at 11:26 a.m. 8) June 22, 2021, Loperamide HCL capsule 2 Mg was administer to resident #1 at 11:03 a.m. 9) June 06, 2021, Vitamin B-12 TAB 1000MCG was administered to resident #1 at 11: 18 a.m. 10) June 14, 2021, Vitamin E 400 EU was administered to resident #1 at 11:26 a.m. B) The May 2021, Medication Administration Records (MARs) scheduled resident #2 to receive his / her medication by 10:00 a.m. The following medications were administered late to resident #2 : 1) May 20, 2021, Venlafaxine HCL ER 37.5 mg was administered to resident #2 at 11:10 a.m. 2) May 27, 2021, Metoprolol Succinate 50 mg tablet was administered to resident #2 at 11:10 a.m. C) The August 2021, Medication Administration Records (MARs) scheduled resident #5 to receive his/her medications by 7:00 p.m. The following medications was administered late to resident #5: 1) 8/15/2021, Buspirone HCL was administered to resident #5 at 9:09 p.m. D) The July 2021, and May 2021, Medication Administration Records (MARs) scheduled resident #3 to receive the following medications by 9:00 a.m. The following medication were administered late: 1) 7/7/2021, DOK Oral Tablet 100 MG was administered to resident #3 at 11:09 a.m. 2) 7/7/2021, Lorazepam Intensol Oral Concentrate 2MG/ML was administered to resident #3 at 11:09 a.m. Risk Rating : B-2
Plan of Correction:	What Has Been Done to Correct: RMAs from all shifts were educated on 7/27/2022 on the importance of adhering to ordered medication times, routes, dosages, etc. How Will Recurrence Be Prevented: A plan was put in place on 7/27/22 to facilitate a mandatory 4 hour refresher course quarterly to ensure, the correct procedures in medication administration are followed. Person Responsible: Executive Director and Assistant Resident Care Director
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	VIOLATION: Based upon the record review, the facility failed to administer all medication in accordance with the physician orders or instructions. EVIDENCE: The facility failed to administer the following medication as per the physician orders, Linzess Oral Capsule 145 MCG take capsule by mouth at 6:00 a.m. for constipations. (DO NOT CRUSH) Resident #5 failed to receive Linzess Oral Capsule on the following dates: 1) 8/19/2021 2) 8/21/2021 3) 8/23/2021 4) 8/26/2021 The August 2021, electronic medication administration records (MARs) indicated that the drug was not available and that the facility was waiting on the pharmacy. Risk Rating: B-2
Plan of Correction:	What Has Been Done to Correct: Resident?s insurance would not pay for the prescribed medication therefore it was unavailable at the community. How Will Recurrence Be Prevented: Will work with prescribing physician to find alternative medication, hold, or discontinue medication until a solution can be found. Person Responsible: Executive Director and Assistant Resident Care Director