VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living At Charlottesville
1550 Pantops Mountain Place
Charlottesville, VA 22911
(434) 977-4094

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: March 16, 2022 , April 5, 2022 and April 11, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced complaint investigation was conducted at the facility on March 16, 2022 by licensing staff from 10:04 a.m. to 1:43 p.m. A tour of the facility was conducted to observe residents. Resident records were reviewed and staff interviews were conducted. There were violations in the following areas: Resident Care and Related Services, Safe Secure Environment. Thank you for your cooperation during this inspection. I can be reached at alex.poulter@dss.virginia.gov or 804-662-9771.

Violations:

Standard #:	22VAC40-73-1090-A
Complaint related:	No
Description:	Based on record review and interview with staff, the facility failed to ensure prior to admission to a safe, secure environment (SSE), the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Resident #4 admitted to the SSE on 7-12-2019. Resident #4?s ?Assessment of Serious Cognitive Impairment? documented, ?No? to the question, ?Is the individual above able to unable to recognize danger or protect his/her own safety and welfare?? by Physician #1. 2. Staff #1 acknowledged during interview that Resident #4 was not assessed as unable to recognize danger or protect his own safety and welfare.
Plan of Correction:	What Has Been Done to Correct? This was in place at time of inspection. Resubmitted the document for review How Will Recurrence Be Prevented? Executive Director and Resident Care Director to review all paperwork prior to admission Person Responsible: Executive Director, Resident Care Director, or designee Due Date: 4/18/22
Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on record review and interview with staff, the facility failed to ensure the uniform assessment instrument (UAI) was completed whenever there is a significant change in the resident's condition. Evidence: 1. Resident #1?s ISP dated 11-17-2021 documented ?catheter? under ?Bladder Management?; however, Resident #1?s UAI dated 9-22-2021 documented ?No? under continence ? bladder for ?Needs Help??. 2. Additionally, Resident #1?s UAI dated 11-17-2021 documented ?No? under eating/feeding for ?Needs Help??; however, Resident #1?s ISP documented on 11-10-2021, ?resident may need to be assisted with feeding and drinking give resident straws?. 3. Staff #1 confirmed during interview that Resident #1?s UAI was not updated with the change in resident?s condition.
Plan of Correction:	What Has Been Done to Correct? Resident 1?s UAI and ISP was updated How Will Recurrence Be Prevented? All information will be reviewed prior to completion and ensure the UAI, and ISP match and the resident is receiving the care that is needed Person Responsible: Executive Director, Resident Care Director, or designee Due Date: ED and RCD to review all resident charts by 5/31/22. Continue monthly chart audits
Standard #:	22VAC40-73-450-D
Complaint related:	No
Description:	Based on record review and interview with staff, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan. Evidence: 1. Resident #1?s ISP dated 11-17-2021 documented, ?Hospice will care for resident as scheduled by hospice? and listed the agency providing services; however, the ISP did not designate which services will be provided by hospice and which services will be provided by the facility. 2. Resident #2?s ISP dated 4-30-2020 did not document hospice services; however, Resident #2 had a recertification as recent as 2-15-2022 through 4-15-2022 for hospice services. 3. Resident #4?s ISP dated 11-15-2020 documented, ?Hospice to provide support and ensure comfort care in place through end of life? and listed the agency providing services; however, the ISP did not designate which services will be provided by hospice and which services will be provided by the facility. 4. Staff #1 confirmed during interview the services provided by each shall be included on the individualized service plan for the aforementioned residents.
Plan of Correction:	What Has Been Done to Correct? ISP was updated to reflect residents current assessed needs to include Hospice Services. How Will Recurrence Be Prevented? The Resident Care Director or designee will review all residents that have hospice services and ensure that their care plans reflect those services. Community will continue to complete Preliminary ISP and Comprehensive ISP in conjunction with resident, family, and/or caregivers while using the History and Physical, physician orders, UAI, and other support to ensure the individualized basic needs of the residents are adequately identified to include type of assistance needed to protect the resident's health, safety, type of assistance required by coordinated services if applicable, and required signatures. Executive Director will complete random monthly audits to ensure ongoing compliance Person Responsible: Executive Director, Resident Care Director, or designee Due Date: ED and RCD to review all resident charts by 5/31/22. Continue monthly chart audits
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on record review and interview with staff, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months. Evidence: 1. Resident #2 admitted 6-08-2015 to the facility. On the date of inspection (3-16-2022), Resident #2?s most current ISP was dated 4-30-2020. 2. Resident #4 admitted 7-12-2019 to the facility. On the date of inspection (3-16-2022), Resident #4?s most current ISP was dated 11-15-2020. 3. Staff #1 acknowledged that documentation was still being updated and that Resident #2 and Resident #4?s ISPs were not reviewed and updated at least once every 12 months.
Plan of Correction:	What Has Been Done to Correct? Resident 2 and 4 were reviewed and ISP has been updated How Will Recurrence Be Prevented? The Resident Care Director or designee will ensure that each ISP is reviewed and updated annually or if there is a change in the resident condition Person Responsible: Executive Director, Resident Care Director, or designee Due Date: ED and RCD to review all resident ISPs by 5/31/22. Continue monthly audits
Standard #:	22VAC40-73-650-B
Complaint related:	No
Description:	Based on record review, the facility failed to ensure physician or other prescriber orders, both written and oral shall identify the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. The following residents? Physicians? Orders did not identify the diagnosis, condition, or specific indications for administering each drug: a. Resident #2?s Physician?s Orders dated 11-16-2021 ? Bisacodyl Rectal Suppository 10mg, Calmoseptine External Ointment 0.44 ? 20.6%, Ensure Chocolate 24 cans, Gabapentin Oral Capsule 100 mg, Triple Antibiotic External Ointment; and b. Resident #4?s Physician?s Orders dated 10-21-2021 ? Docusate Sodium Oral Capsule 100 mg, Loperamide HCI Oral Capsule 2 mg.
Plan of Correction:	What Has Been Done to Correct? All physician?s orders are being reviewed, updated, and signed to include a diagnosis for all medications. How Will Recurrence Be Prevented? Physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements will include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. Person Responsible: The Resident Care Director and the Assistant Resident Care Director are responsible for ensuring physician?s orders include a diagnosis Due Date: RCD to review all resident orders by 5/6/22 and ongoing