VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Front Royal
600 Mount View Street
Front royal, VA 22630
(540) 636-2800

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: April 29, 2019

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 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

Technical Assistance:

Discussion occurred on the following topics: 1) Ensure mechanical supports are consistently identified on the ISP. 2) Orientation and resident rights to be reviewed with the resident; acknowledgment to be maintained in resident's record. 3) Resident to be offered copy of ISP and acknowledgement to be maintained in resident's record. 4) Ensure orders as they relate to blood pressure, blood glucose, pulse rate, O2 saturation and weights consistently include parameters as when to notify physician. 5) Night shift fire drill to be completed by April 30th. 6) Mobility refers to movement outside of the facility. 7) Recommendation to obtain medication review for hospice residents and residents discussed. 8) Oxygen orders to identify source and to include portability.

Comments:

An unannounced monitoring inspection was completed by two LIs on 04/29/2019. There were 73 residents in care. The facility was clean and free from any foul odors. The activities calendar and menu accurately reflected what the LIs observed. Criminal history reports were reviewed. April medication administration records were reviewed for a select number of residents. Ten resident and five staff records were reviewed. There were four violations during this monitoring inspection relating to medication administration. Details of non-compliance can be viewed in the violation notice section of this report. If you have any questions, please call your licensing inspector at (540) 332-2330 or email rhonda.whitmer@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-40-A
Description:	Based upon review of resident's Medication Administration Records (MARs) and the facility medication management plan, the licensee failed to ensure compliance with its own policy and procedures. EVIDENCE: 1) The medication management plan indicates that the MARs will be reviewed weekly by a licensed nurse or medication aide designee to ensure safe practices 2) The medication management plan indicates medication aides will administer PRN medication when the facility has obtained from the resident's physician, orders that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24 hour period, and directions as to what to do if symptoms persist. 3) The medication management plan indicates the medication aide will contact Resident Care Director if PRN medication does not have desired outcome within 60 minutes. 4) The medication management plan indicates the Resident Care Director should review the order, verifying the accuracy of the entry in the electronic system and availability of the medication. 5) The medication management plan indicates the Resident Care Director should review the pharmacy log every morning to ensure all new medications have been received by the pharmacy. 6) The medication management plan indicates if the resident is taking a new medication and there are signs and symptoms of a possible allergy, notify the resident's primary physician . At any time a new allergy is noted or identified, the Resident Care Director/LPN will notify the resident's primary care physician and the pharmacy and update the resident's medical record. a. The medication management plan does not address allergies to dietary supplements as required by 22 VAC 40-73-640A #12. 7) The medication management plan indicates medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. 8) The medication management plan indicates if a medication is missed/refused to notify physician immediately or according to the parameters as indicated by the physician. Physician parameters must be retained in writing and filed in the chart under Physician Orders and responsible party is notified. 9) The medication management plan indicates if vital signs are taken to determine need for administration of medication, parameters are indicated on the MAR. 10) The medication management plan indicates the Resident Care Director will routinely monitor the community medication procedures to ensure conformance with the medication management plan.
Plan of Correction:	Resident Care Director conducted mandatory training and review of facility medication management plan with all registered medication aides on Thursday, May 9th, 2019. Additional Healthcare oversight was provided onsite by Sandi Flores Consulting Group on Monday, May 13th, 2019. Sandi Flores Consulting Group also conducted a pharmacy review on Tuesday, May 21st, 2109. Registered Medication Aides will receive ongoing training with Resident Care Director and Executive Director regarding medication management monthly and as needed. Resident Care Director met with Blue Ridge Hospice and reviewed all current hospice residents and their physician?s orders and MARs, making changes and documenting as needed. The Resident Care Director or Assistant Resident Care Director will reference the resident?s history and physical to ensure that no resident receives food, medications, or dietary supplements in which they have an allergy. All resident allergies will be documented on the MAR and will be audited and reviewed monthly by the Executive Director or Resident Care Director. If a resident refuses their medication, the registered medication aide on duty will notify physician via fax and Resident Care Director or Assistant Resident Care Director will review medication refusal notifications weekly. The Resident Care Director or Assistant Resident Care Director will review the pharmacy log daily to ensure medications that were ordered are delivered by the pharmacy and if medication is not available for administration, facility back up pharmacy will be notified and a note will be made. Resident Care Director and Assistant Resident Care Director will obtain the medication from the local backup pharmacy.
Standard #:	22VAC40-73-680-D
Description:	Based upon review of residents' Medication Administration Records (MARs), the facility failed to ensure medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1) Resident H has the following orders effective 03/13/2019: Hydrocodone 5-325mg-Take 0.5 tablet by mouth every 6 hours for pain and Hydrocodone 2.5/325mg-take 2 tablets by mouth every 6 hours as needed for verbalized pain. a. The MAR for resident H does not include Hydrocodone 5-325mg-Take 0.5 tablet by mouth every 6 hours for pain. 2) Resident H has the following order: Blood pressure and pulse-Obtain and record BP and pulse twice daily prior to administering Metoprolol. a. Documentation in the MAR indicates resident's BP was 109/64 on 04/24/19 at 9:00pm. b. Documentation in the MAR indicates Metroprolol was administered on 04/24/19 at 9:00pm. 3) Resident J has the following order: Hydrocodone 5-325mg-Take one tablet by mouth every 6 hours as needed for breakthrough pain that is not reduced by Tylenol. a. Documentation indicates medication was administered on 04/03, 04/05, 04/09 through 04/11, 04/14 through 04/16, 04/18 through 04/26 and on 04/28/2019. There is no record of Tylenol being administered prior to administration of Hydrocodone on the listed dates. 4) Resident K has the following order: Baclofen 5mg-Take 1/5 (2.5mg) by mouth three times daily. a. Documentation in the MAR indicates medication was not available for administration on 04/02/19 at 7:00am and 3:00pm. 5) Resident K has the following order: Buspirone HCL 10mg-Take one tablet by mouth three times daily. a. Documentation in the MAR indicates medication was not available for administration on 04/08/2019 at 3:00pm. 6) Resident L has an order for Amlodipine to be given once a day for hypertension. The MAR indicates that resident has an allergy to Amlodipine and the medication review completed on 02/12/2019 indicates resident has allergy to Amlodipine. The review requests verification and to document appropriately. 7) The MAR for resident M indicates duplicate orders for PRN Acetaminophen suppository. 8) Resident N has the following order: Morphine Sulfate 20mg/ml- Give 0.25ml every 4 hours as needed for pain. a. Documentation in the MAR indicates medication was administered on 04/28/2019 at 7:37 due to resident being short of breath. 9) Resident N has the following order: Hydrocodone 5-325mg-For verbalized pain if Tylenol ineffective. a. The MAR for resident N indicates medication was administered on 04/01 through 04/03, 04/05 through 04/07, 04/08 through 04/11, 04/13, 04/15 through 04/26 and 04/28/2019. There is no record of Tylenol being administered prior to administration of Hydrocodone on the listed dates.
Plan of Correction:	Executive Director and Resident Care Director will ensure that all residents? medications are administered in accordance with physician or other prescriber?s instructions. Resident Care Director conducted a mandatory training on Thursday, May 9th, 2019 and reviewed specific topics such as following physician?s orders, PRN medication orders, and proper documentation as it relates to PRN medications and specific parameters. The facility?s medication management plan was reviewed thoroughly and will be reviewed with registered medication aides monthly and as needed. If PRN medication is not effective, Registered Medication Aide will contact Resident Care Director or Assistant Resident Care Director, who will then notify the resident?s primary care physician for guidance on next steps. The Executive Director and Resident Care Director will ensure all PRN orders include the following per regulatory guidelines: a) symptoms indicating the use of medication b) exact dosage c) the exact time frames the medication is to be given in a 24 hour period d) directions as to what to do if symptoms persist and e) results of PRN medication and follow up if applicable. The Executive Director and Resident Care Director will perform bi monthly unannounced medication pass observations. The Executive Director and Resident Care Director will audit Quickmar weekly to monitor and maintain regulatory compliance.
Standard #:	22VAC40-73-680-I
Description:	Based upon review of resident's Medication Administration Records (MARs), the facility failed to ensure all required information is included in the MAR. EVIDENCE: 1) Resident H has the following order: Lorazepam 0.5mg tablet-Take one tablet by mouth 3 times a day as needed for hitting, kicking, constantly trying to get up on her own. a. Documentation in the MAR indicates medication was administered on 04/05/2019 at 4:07pm. Documentation of results indicate medication was not effective. There is no documentation of follow-up in the MAR. 2) Resident H has the following order: Hydocodone 2.5-325mg-Give two tablets by mouth every 6 hours as needed for verbalized pain. a. Documentation in the MAR indicates medication was administered on 04/05/2019 at 4:06pm and 04/26/2019 at 3:01pm. Documentation of results indicate medication was not effective. There is no documentation of follow-up in the MAR. 3) Resident I has documented refusals on 04/07, 04/08, 04/11, 04/12, 04/14, 04/16, 04/17, 04/18 through 04/22/19. There is no documentation of physician notification in the MAR. 4) Resident S has documentation of refusals on 04/01, 04/02, 04/17, 04/19, 04/22, 04/25, 04/26 and 04/28/2019. There is no documentation of physician notification in the MAR.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-K
Description:	Based upon the review of residents' Medication Administration Records, the facility failed to ensure PRN orders include all required information. EVIDENCE: 1) Resident A has a PRN order for Lorazepam. The order does not include directions as what to do if symptoms persist. 2) Resident B has PRN orders for Combivent inhaler and Nystatin powder. The orders do not include directions as what to do if symptoms persist. 3) Resident F has PRN orders for Ipratropium/Albuterol inhalant solution and Ondansetron. The orders do not include directions as what to do if symptoms persist. 4) Resident H has PRN orders for Lorazepam, Omeprazole and Oxygen. The orders do not include time frame to notify hospice if symptoms persist. 5) Resident I has a PRN order for Refresh eye drops. The order does not include exact time frame medication is to be given in a 24 hour period. 6) Resident J has a PRN order for Morphine. The order does not include directions as what to do if symptoms persist. 7) Resident K has PRN orders for Calmoseptine, Lactulose, Lorazepam and Nystatin powder. The orders do not include directions as what to do if symptoms persist. 8) Resident N has an order for Hydrocodone that does not indicate exact time frame medication is to be given in a 24 hour period. 9) Resident O has PRN orders for Nystatin powder, Orajel and Systane eye drops. The orders do not include directions as what to do if symptoms persist. 10) Resident P has a PRN order for Acetaminophen. The order does not include directions as what to do if symptoms persist. 11) Resident Q has a PRN order for Acetaminophen. The order does not include directions as what to do if symptoms persist. 12) Resident R has PRN orders for Albuterol, Melatonin, Miralax, Morphine, Tramadol and Zofran. The orders do not include directions as what to do if symptoms persist.
Plan of Correction:	Not available online. Contact Inspector for more information.