VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Williamsburg
236 Commons Way
Williamsburg, VA 23185
(757) 564-4433

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: May 11, 2023 , Aug. 1, 2023 , Dec. 15, 2023 and Dec. 20, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint An unannounced complaint inspection was conducted on 5-13-23 (Ar 10:03/dep 4:35 p.m) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection by the new administrator, the former administrator was also present. A complaint was received by VDSS Division of Licensing on 05/05/23 regarding allegations in the discharge and medication, resident care and related services. Number of residents present at the facility at the beginning of the inspection: 118 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations area(s) of non-compliance with standard(s) or law were valid A violation notice was issued; any violation(s) not related to the complaint 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. 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 (Willie Barnes), Licensing Inspector at 757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-C
Complaint related:	Yes
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure medication was administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule. Evidence: 1. During a complaint investigation regarding medication administration, resident #1?s medication administration record (MAR) from December 2022 to May 3, 2023, noted medications were administered earlier than one hour before and later than one hour after the facility?s standard dosing schedule for the following medications: (a) Amlodipine 5mg at 8 a.m. 1 time (1x) in December 2022 and February 2023, 2x in March 2023 and 1x in April 2023. (b) Aspirin 81 mg at 8 a.m. 1x in January 2023, 2x in February, March, and April 2023. (c) Lipitor 10mg at 8 p.m., 9x in January and February 2023, 6x in March, 4x in April and 1x in May 2023. (d) Sinemet 25-100 mg at 7:30 a.m. and 11:30 a.m. and 4:30 p.m., 4x in December 2022, 9x in January, 5x in February, 2x in March and 1x in April (e) Coreg 12.5 mg at 8 a.m. and 8 p.m., 4x in December 20223, 9x in January, 9x in February, 2x in March, 3x in April and 1x in May 2023. (f) Famotidine 10mg at 4:30 p.m. 8x in February 2023. (g) Melatonin 6mg at 8 p.m., 4x in December 2022, 9x in January and February, 3x in March 2023. (h) Singular 10mg at 8 p.m., 4x in December 2022, 9x in January and February, 5x March, 4x April and 1x May 2023. (i) Loratadine 10mg at 8 a.m., 1x in January and February and 2x in March and April 2023. (j) Thera-M at 8 p.m., 4x in December 2022, 9x in January and February 2023, 3x in March, 4x in April and 1x in May 2023. 2. Staff #1 acknowledged the medications were not given at the dosing scheduled time.
Plan of Correction:	Plan of correction: Review and re-educate all Registered medication aides on medication administration policy dosing schedule to focus on strict adherence. Monthly med pass audit of RMA administering medications for three months then quarterly to ensure compliance of policy. ? RCD/ED/Designee to be completed -initiated 1/12/24 then ongoing.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure medications was administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. On 5-13-23 during a complaint investigation regarding medication administration, resident #1 March 2023 medication administration record (MAR) noted resident was prescribed Sinemet 25-100mg, take on and one-half tablet(s) 37.5-150 at 7:30 a.m. and 11:30 a.m. The facility medication log noted the resident was administered one, (1) tablet at the 11:30 a.m. dosing time fourteen (14) times from 3-7-23 to 3-20-23 by five different registered medication aides. 2. Staff acknowledged the resident was not administered the medication according to the prescribed dosage.
Plan of Correction:	Plan of Correction: All clinical personnel instructed to cease from making any changes to medication dosing in the Electronic Medication Record. Pharmacy will make all changes to medication dosages and frequency per physician orders. To be reviewed and approved by RCD/Designee prior to completion - effective immediately and ongoing