VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at the Eastern Shore
23610 North Street
Onancock, VA 23417
(757) 787-4343

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: May 1, 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 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 FACILITIES AND PROGRAMS 22VAC40-80 THE LICENSE

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: An unannounced monitoring inspection took place on 05/01/24 from 8:50 am to 4:05 pm. A self-reported incident was received by VDSS Division of Licensing on 02/02/2024 and 02/09/24 regarding allegations in the area of: Administration and Administrative Services and Resident Care and Related Services 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: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for three residents. The following were reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-40-A
Description:	Based on the record review the facility failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department, with relevant federal, state, and local laws; with other relevant regulations; and with the facility?s own policies and procedures. Evidence: 1. The facility?s medical emergencies policy and procedure includes the following: ?resident will receive emergency medical care when needed to prevent further injury or illness; signs and symptoms of a medical emergency include but not limited to: falls, and sudden onset of pain. The community will call Emergency Medical Services (911) when a resident exhibits signs and symptoms of distress and/or a medical emergency. If the condition is trauma or an issue non-related to the hospice condition, 911 will be called.? 2. Resident?s #1 Incident report dated 02/08/24 documents the following: ?investigation revealed that on 01/28/24 at 1:30 am resident was observed on the floor during status check:? ?staff observed abrasions to arm and provided first aid;? ?investigation also determined that staff did not call 911 per policy for an unwitnessed fall for a memory care resident;? ?on 02/01/24 it was reported to community, hospice nurse that resident had a fracture to right hip;? ?it is determined that the fracture may have been sustained during fall on 01/28/24;? ?retraining with staff on community fall policy & 911 calls to include residents receiving hospice services.? 3. Resident?s #1 progress notes includes the following: 01/27/24 @ 6:01 am: ?resident complained of hip pain.? 01/27/24 @ 8:34 am: ?resident complained of pain to right hip.? 01/27/24 @ 4:11pm: ?resident complained of right leg discomfort.? 01/28/24: ?resident try using the bathroom alone and fell and sustained 2 small skin tears on her right shoulder.? 01/29/24: ?resident complained of leg pain.? 01/30/24: ?resident could not stand due to leg pain.? 02/01/24: ?resident sent to the hospital to get x-rays done.? The resident?s record did not contain documentation the resident received emergency medical care during the dates of 01/27/24 to 01/31/24.
Plan of Correction:	What Has Been Done to Correct? Staff has been retrained to follow policy with regard to 911 calls for any residents exhibiting signs & symptoms of distress or medical emergency. Assessments of all residents completed to ensure none are currently in distress or in need of medical emergency attention. How Will Recurrence Be Prevented? Any resident exhibiting signs & symptoms of distress or need of medical emergency attention will immediately be sent to local ER for evaluation & treatment. Person Responsible: RCD/ARCD/ED