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: April 26, 2022

Complaint Related: No

Areas Reviewed:

REVIEWED AREAS OF STANDARDS ? 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 ? 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

Technical Assistance:

Administrator approval for placement in SCU

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: 4-26-2022 11:28 a.m. ? 2:15 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review and interview with staff, the facility failed to ensure the resident?s physical examination contained a descriptions of the person?s reactions to any known allergies. Evidence: 1. Resident #1 admitted 4-01-2022. Resident #1?s Report of Resident Physical Examination dated 3-30-2022 documented allergies to ?Fluoroquinolones, Mold, and Flagyl?; however, no reactions to the allergies were listed. 2. Resident #3 admitted 12-27-2021. Resident #3?s Report of Resident Physical Examination dated 12-20-2021 documented allergies to ?Ace inhibitors and Tetracyclines & related?; however, no reactions to the allergies were listed.
Plan of Correction:	What Has Been Done to Correct? Reactions to known allergies have been added to the care plan and face sheet for Resident #1 and Resident # 3 How Will Recurrence Be Prevented? Executive Director and Resident Care Director will ensure that History and Physical document is reviewed for required information and signatures prior to being admitted to the facility. Thorough medication and allergy audit and review of current residents by RCD, ED, house PCP and partnering pharmacy. Person Responsible: The Executive Director, Resident Care Director, or designee are responsible for ensuring any allergy has a listed reaction.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the comprehensive individualized service plan (ISP) included the description of identified needs based upon the UAI [uniform assessment instrument] and admission physical examination. Evidence: 1. Resident #1 admitted 4-1-2022. Resident #1?s UAI dated 3-29-2022 documented the resident is ?incontinent less than weekly? for bladder and bowel assistance as an identified need; however, the resident?s comprehensive ISP dated 4-22-2022 did not address bowel and bladder incontinence. 2. Resident #2 admitted 2-10-2022. Resident #2?s UAI dated 3-12-2022 documented bladder ?incontinent less than weekly? as an identified need; however, Resident #2?s comprehensive ISP dated 3-1-2022 did not address bladder incontinence. Additionally, the same UAI documented, ?mechanical help, human help, supervision? with mobility as an identified need; however, the same ISP did not address mobility assistance. Lastly, Resident #2?s Report of Resident Physical Examination dated 2-08-2022 documented resident?s allergy to ?Meperidine causes anxiety?; however, the allergy and reaction were not on the ISP. 3. Resident #3 admitted 12-27-2021. Resident #3?s UAI dated 3-03-2022 documented resident requires ?mechanical help, human help physical assistance? with dressing as an identified need; however, the resident?s comprehensive ISP dated 3-03-2022 documented ?resident requires assistance with dressing, caregiver dresses/undresses and selects clothing but resident is able to assist in task?. Additionally, the resident?s UAI documented a need for assistance with toileting ?mechanical help, human help physical assistance?; however, the same ISP documented, ?Adult Briefs Resident requires physical assistance with all tasks related to toileting. May require assistance with closed drainage system/catheter?. 4. Resident #4 admitted 5-01-2021. Resident #4?s UAI dated 4-08-2022 documented ?incontinent weekly or more? for bowel and bladder as identified needs; however, the comprehensive ISP dated 4-14-2022 documented ?continent? for bowel and bladder assistance. 5. Resident #5 admitted 9-14-2018. Resident #5?s UAI dated 3-04-2022 documented resident requires ?mechanical help? with dressing as an identified need; however, the comprehensive ISP dated 11-20-2021 documented, ?Resident can dress/undress and select clothing with physical assistance. Make sure [Resident #5] is odor free and dressed in appropriate clothing for season?. 6. Resident #7 admitted 5-25-2021. Resident #7?s UAI dated 4-14-2022 stated ?no? for assistance with money management; however, the comprehensive ISP dated 4-15-2022 documented ?Resident is unable to handle financial business matters; resident has a designated person(s) to manage finances? as an identified need. Additionally, the UAI documented ?mechanical help, human help physical assistance? for stairclimbing as an identified need; however the ISP did not address stairclimbing. 7. Resident #8 admitted 8-28-2019. Resident #8?s UAI dated 1-19-2022 documented ?physical assistance? with dressing as an identified need; however, the comprehensive ISP dated 1-26-2022 documented ?Resident can dress/undress and select clothing but may need to be reminded/supervised? for dressing.
Plan of Correction:	What Has Been Done to Correct? The ISP and UAI for Residents #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #7, Resident #8 were reviewed and updated to reflect the residents current assessed needs. How Will Recurrence Be Prevented? Executive Director, Resident Care Director or designee will audit UAI and ISP upon completion to ensure all needs are addressed in real time. All current Resident UAI and ISP will be reviewed and updated as needed. All UAI?s and ISP?s will be reviewed by Executive Director and Resident Care director bi annually for compliance and accuracy. Person Responsible: Executive Director, Resident Care Director, or designee
Standard #:	22VAC40-73-490-D
Description:	Based on record review and interview with staff, the facility failed to ensure the specific residents for whom the health care oversight was provided was identified. Evidence: 1. The health care oversight dated 6-01-2021 through 6-30-2021 did not have a list of residents included in the oversight along with it. 2. Staff #1 confirmed during interview that there was no list of residents included with the oversight as Staff #1 stated that it was known that this was required.
Plan of Correction:	What Has Been Done to Correct? Executive Director and Resident Care Director educated nurse consultant performing the healthcare oversight to ensure that a list of residents reviewed is identified and listed on the form. How Will Recurrence Be Prevented? Executive Director and Resident Care Director will audit Health Care Oversight paperwork before it is completed to ensure that a list of residents is captured. Person Responsible: Executive Director, Resident Care Director, or designee
Standard #:	22VAC40-73-560-F
Description:	Based on observation and interview with staff, the facility failed to ensure all records were made available for inspection by the department's representative. Evidence: 1. During onsite inspection on 4-26-2022, Resident #2 through Resident #8?s records as well as Staff #3 through Staff #6 were locked in the administrative office (Staff #1?s office) that Staff #2 was not permitted access to due to Staff #1 being out of the community. 2. Staff #1 stated during a phone call with the licensing inspector following the 4-26-2022 inspection date, ?Typically the records are not kept locked in [Staff #1?s office]; however, they were doing a record-wide audit.?
Plan of Correction:	What Has Been Done to Correct? Files that were being audited were removed from the Executive Director?s office and placed in an accessible safe area for staff reference as needed. How Will Recurrence Be Prevented? A key to the Executive Director?s office was made and given to the Business Office Manager to keep onsite in case emergency access is needed. Person Responsible: Executive Director or designee
Standard #:	22VAC40-90-50-B
Description:	Based on record review and interview with staff, the facility failed to ensure each criminal history record report shall be verified by the operator of the facility by matching the name, social security number and date of birth to establish that all information pertaining to the individual cleared through the Central Criminal Records Exchange is exactly the same as another form of identification such as a driver's license. If any of the information does not match, a new criminal history record request must be submitted to the Central Criminal Records Exchange with correct information. 1. Staff #3 was hired 4-1-2020. The criminal history record report on file (dated 4-2-2020) was for a differently spelled name than Staff #3 and no report was resubmitted within 30 days with the correct name. 2. Staff #1 confirmed Staff #3?s report was not resubmitted until discovered during the inspection.
Plan of Correction:	What Has Been Done to Correct? The criminal history record report was resubmitted when it was discovered the spelling of an employee?s last name was wrong. How Will Recurrence Be Prevented? Executive Director and Business Office manager will continue to review pre-hire paperwork with staff to ensure all information is accurate. Review and audit all new employee files quarterly for compliance. Person Responsible: Executive Director, Business Office Manager, or designee