VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Cedar Bluff
500 Clinic Drive
Cedar bluff, VA 24609
(276) 596-9750

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: May 8, 2019

Complaint Related: No

Areas Reviewed:

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

Comments:

Three licensing inspectors conducted a one day license renewal inspection at Commonwealth Senior Living at Cedar Bluff on May 08, 2019. The inspection started at 10:25 a.m. and concluded at 2:45 p.m. Resident files were reviewed and the noon medication pass was observed. Medication Administration Records, medications, and physician's orders were reviewed. A tour of the building and grounds was completed and lunch was observed. Residents and collaterals were interviewed. The first aid kit and blood glucose monitoring supplies were observed and reviewed. Required postings were observed in the facility. Previous violations were reviewed to determine correction and compliance with standards. Areas of non-compliance are identified on the attached violation notice. An exit meeting was conducted with the administrator on 05/08/2019 and the findings were reviewed. Opportunity was given to find items that were not available in the records. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days (05/20/2019) of receipt. If you have questions or concerns, please feel free to contact your inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-1110-B
Description:	Based upon review of resident records, the facility failed to perform a review of appropriateness for one out of three resident's continued residence in the special care unit after six months of placement and annually thereafter. EVIDENCE: Resident #1 was admitted to the special care unit on 08/08/2017. The first review date was 10/02/2018.
Plan of Correction:	ED assured current approval for placement was in chart for resident #1. ED/RCD will assure approval for placement in special care form is complete before a resident placed in the sweet memory care neighborhood with a follow up within 6 months. All other charts will be reviewed for accuracy. Staff will be re-educated on proper forms to be completed. RCD will perform random monthly chart audits to ensure ongoing compliance. [sic]
Standard #:	22VAC40-73-120-C
Description:	Based on staff interviews, the facility failed to train all direct care and medication aide staff sufficiently to have knowledge of the location of the first aid kit. EVIDENCE: 1. The Licensing Consultant asked the location of the first aid kit. 2. Staff # 2 searched in the secure unit and the activity directors office and was unable to locate the first aid kit. 3. Staff # 3 searched two medication rooms in the back of the building and was unable to locate the first aid kit. 4. Two direct care staff were asked where a first aid kit was located and they responded that if staff # 3 could not find it, they did not know where it was located. 5. After approximately 15 minutes of different staff searching for the first aid kit staff # 4 located the first aid kit in the medication aide room.
Plan of Correction:	All staff will be re-educated through in-service on location of first aid kits. Date of compliance 05/22/2019. ED/RCD will randomly quiz all staff on location of first aid kits. Date of compliance 05/08/2019. [sic]
Standard #:	22VAC40-73-290-A
Description:	Based upon observations made during the tour of the building, the facility failed to maintain a written work schedule that includes an indication of whomever is in charge at any given time. EVIDENCE: 1. The facility staff work schedule for May did not indicate who was in charge at any time. Staff #1 confirmed it was always a RMA, when the administrator was not present but this was not reflected on the schedule.
Plan of Correction:	Work schedule was corrected on 05/08/2019 with name of person in charge and will be maintained with any changes noted on schedule. Staff will be re-educated through in-service. ED/RCD will monitor for compliance. [sic]
Standard #:	22VAC40-73-320-A
Description:	Based upon review of resident records, the facility failed to obtain all required information in on the physician exam performed prior to admission for one resident in the sample of eight. EVIDENCE: 1. Resident #2 was admitted on 02/04/2019, his physical was dated 01/15/2019. The height and weight were left blank by the physician's office. 2. The question addressing Resident #2's ability to self administer medications was left blank.
Plan of Correction:	Resident #2 history and physical reviewed and updated by physician on 05/08/2019. ED or RCD will assure all history and physicals are completed accurately and on file prior to admission. ED or RCD will complete random monthly audits with a minimum of 5 resident charts to ensure ongoing compliance. [sic]
Standard #:	22VAC40-73-450-C
Description:	Based upon review of resident records, the facility failed to complete the comprehensive Individual Service Plan (ISP) within 30 days after admission and shall include all services that will be provided to the resident. EVIDENCE: 1. Resident #2 wad admitted on 02/01/2019. His comprehensive ISP was completed 03/05/2019. 2. Resident #3 was admitted on 06/11/2018. His comprehensive ISP was dated 10/07/2018. 3. Resident # 6 was admitted to Hospice on 03/21/2019. Hospice services and care were not addressed on her ISP dated 03/12/2019.
Plan of Correction:	Resident #6 ISP was updated to reflect change in condition on 05/08/19. ED/RCD or designee will continue to complete preliminary ISPs and updated in 30 days or in the event of a significant change. Records will be reviewed to identify needs and type of assistance to coordinate services identified. Staff will be re-educated through in-services. ED/RCD will complete random monthly audits of a minimum of 5 comprehensive ISP's to ensure ongoing compliance. [sic]
Standard #:	22VAC40-73-460-E
Description:	Based on documentation review, the facility failed to document in one residents file a notable change in the resident?s condition. EVIDENCE: 1. Admission and discharge notes from a local hospital state that Resident # 6 was admitted to the hospital on 03/20/2019 and discharged back to the facility on 03/21/2019. 2. There was nothing documented in facility Narrative Charting regarding the admission or discharge from the hospital. The documentation that was available in Narrative Charting stated that Resident # 6 was sent to a local hospital at 10:00 p.m. on 03/19/2019.
Plan of Correction:	Resident #6 chart was updated with all pertinent information. ED/RCD or designee will observe each resident and document any significant change in condition and/or assistance with unmet needs and will be documented in the resident's chart. This will be monitored daily with end of shift reporting and daily monitoring of each resident. Staff will be re-educated on documentation and narrative charting. ED/RCD or designee will complete random monthly audits with a minimum of 5 resident charts to ensuer ongoing compliance. [sic]
Standard #:	22VAC40-73-560-E
Description:	Based on observations made during the tour of the building, the facility failed to maintain all components of resident records in a locked area. EVIDENCE: 1. At approximately 10:30 a.m. and 1:00 p.m. resident specific Narcotic sheets were observed on top of a cabinet in the unlocked staff work station in the secure unit.
Plan of Correction:	All resident records were placed in a locked area in Sweet Memories neighborhood on 5/8/19. ED/RCD will monitor daily for accuracy and staff will monitor daily for accuracy and staff will be re-educated on resident records being kept in a locked area. [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on documentation review and staff interview, the facility failed to implement their medication management plan that addresses methods for ensuring accurate counts of all controlled substances when medication administration staff change. EVIDENCE: 1. At 10:30 a.m. the controlled substance (Narcotic) count between medication administration staff had not been documented completed at the 7:00 a.m. morning change of shift. 2. Staff # 2 reported that the count had been completed that morning but she and the off going staff person had failed to document the count for any of the residents Narcotics in the secure unit.
Plan of Correction:	All current RMA's will be re-eduated on end of shift narcotic counting with signatures every shift change. ED/RCD will perform daily audits of narcotic books for ongoing accuracy. [sic]
Standard #:	22VAC40-73-650-A
Description:	Based on documentation review, the facility failed to follow physician?s orders for one residents as needed (PRN) medication. EVIDENCE: 1. Resident # 6 has a physician?s order dated 03/21/2019 for Tylenol 650 mg take 1 tablet by mouth every 8 hours as needed. 2. The Medication Administration Record (MAR) and packaging instruct to administer Tylenol 650 mg take 1 tablet every 4 hours as needed.
Plan of Correction:	Resident #6 order for Tylenol was reviewed for accuracy. MAR and packaging were adjusted and accurate per physician order on 05/08/19. ED/RCD will review all orders and compare MAR to ensure accuracy. ED/RDC will perform weekly 5 chart/med cart audits for ongoing accuracy of physician orders to MAR. Staff will be re-educated through in-service and training. [sic]
Standard #:	22VAC40-73-650-E
Description:	Based on review of resident records, the facility failed to maintain the physician?s or other prescriber?s orders organized chronologically in the resident?s record. EVIDENCE: 1. On April 30, 2019 Resident # 3 was prescribed Vitamin C 500 mg to take two tablets (1000mg) by mouth once a week on Wednesday and Famotidine 20 mg to take one tablet by mouth daily as needed. 2. Both of these physician?s orders for resident # 3 were located in a to be filed folder and not in the resident?s record. 3. On April 29, 2019 resident # 4 was prescribed Albuterol Sulfate (2.5 mg/3ml)0.083% to inhale 1 vial via nebulizer every four hours as needed. 4. The physician?s order for this medication was located in a to be filed folder and not in the resident?s record. 5. A stack of unfiled resident specific information, including physician?s orders dating back to April 20,2019 were observed in a cabinet in the medication aide room. 6. These physician?s orders were not organized chronologically in resident?s records.
Plan of Correction:	Records for residents 33 and #4 were filed and in order on chart 05/08/19. All other filing has been filed appropriately and up to date. ED/RCD will monitor daily to ensure resident records will be maintained, organized, and in chronological order. Staff will be re-educated through in-service. [sic]
Standard #:	22VAC40-73-650-F
Description:	Based on documentation review and staff interviews, the facility failed to obtain new physician?s orders for all medications and treatments post hospital discharge for one resident in the sample of one. EVIDENCE: 1. According to facility Narrative Charting, Resident # 6 was sent to a local hospital at 10:00 p.m. on 03/19/2019. 2. Documentation from the hospital states that Resident # 6 was admitted to the hospital on 03/20/2019 and was discharged from the hospital, back to the facility on 03/21/2019. 3. The facility did not obtain physician?s orders for Coconut Oil; Ketoconazole Cream; Potassium Chloride; ABHR Gel; Maalox; Compression Stockings; Ativan and Zinc Oxide. The facility was administering these seven medications and one treatment to Resident # 6 without signed physician?s orders. 4. There was no documented contact with Resident #6's primary care physician regarding medication orders post hospital discharge.
Plan of Correction:	Hospice was contacted and orders were obtained on 05/08/19 for resident #6. All other resident charts will be checked to ensure there is no absence of physician orders for medications and/or treatments. ED/RCD will monitor all residents returning from hospital for physician orders. Staff will be educated on chart review and documentation. ED/RCD or designee will complete random montly audits with a minimum of 5 resident charts to ensure ongoing compliance. [sic]
Standard #:	22VAC40-73-680-D
Description:	Based on a medication cart audit, documentation review, staff interviews, and medication pass observation, the facility failed to administer all medications in accordance with the physician?s instructions or consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. The medication cart in the secure unit contained an opened Flonase Nasal spray for Resident #1. There was no opened date noted/documented on the medication container or packaging. 2. Resident # 5 has a physician?s order for Ensure 1 can with meal after food intake three times weekly. Staff # 2 gave resident # 5 the Ensure at 11:15 a.m. prior to lunch being served.
Plan of Correction:	Resident #1 Flonase nasal spray was corrected with open date on 05/08/2019. Staff #2 was re-educated on resident #5 physician order for Ensure. All medications will be administered in accordance with physician orders. Staff will be re-educated through in-services and monitoring. ED/RCD will perform a weekly med cart audit and routine med pass audit for ongoing compliance. [sic]
Standard #:	22VAC40-73-680-I
Description:	Based on documentation review, the facility failed to maintain all required components on each Medication Administration Record (MAR) for one resident in the sample of four. EVIDENCE: 1. Resident # 6 has a physician?s order for Vitamin B-12 1 tablet daily by mouth. The MAR instructs to administer this oral medication topically.
Plan of Correction:	MAR was corrected to reflect physician order for Vitamin B12 to be taken orally on 05/08/19. ED/RCD will review all orders and compare to MAR to ensure accuracy. ED/RCD will perform weekly 5 chart/med cart audits for ongoing accuracy of physician orders to MAR. Staff will be re-educated through in-service and training. [sic]
Standard #:	22VAC40-73-860-I
Description:	Based on observations made during the morning tour of the building, the facility failed to ensure all cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: 1. The Licensing Inspector observed the laundry room across from the entrance to the kitchen to be unlocked at approximately 10: 45 a.m. The door had a key pad lock on the outside of the door, however; the door was not secure and the Licensing Inspector was able to open the door by pushing on it. 2. Inside the laundry room the inspector found a large container of glass bright and snapout both heavy duty cleaners above the sink and both products had warning labels stating keep out of reach of children. 3. A bottle of Nyco Triad cleaner was found in a box underneath the sink with a warning label stating keep out of reach of children. 4. The storage closet at the end of the 400 hallway was observed to be open at approximately 11:00 a.m . The Licensing Inspector was able to open the door by pushing on it. The Licensing Inspector observed 3 bottles of Nyco Triad Cleaner, 5 containers of glass bright cleaner, 3 containers of Knontroe apple spice cleaner, 4 containers of carpet cleaner, 3 containers of snapout cleaner, 2 bottles of TASK cleaner, 6 bottles of furniture polish, and six bottles of Lysol cleaner. 5. All of these products contained a warning label to keep out of reach of children. 6. At approximately 10:30 a.m. furniture polish was observed in an unlocked cabinet in the staff work station on the secure unit for memory impaired residents. 7 . The Administrator questioned the locking mechanism on the staff station. The Licensing Consultant accompanied the Administrator to the memory care unit at approximately 1:00 p.m. The cabinet was still unlocked in the staffing station containing the furniture polish.
Plan of Correction:	All doors including laundry room, housekeeping supply closet, nurses station in Sweet Memories neighborhood, were checked and all locks are in working order as of 05/08/19. ED/RDC, MD or designee will ensure that all doors remain locked with daily rounding and frequent checks. Staff will be in-serviced on safety. [sic]
Standard #:	22VAC40-73-870-B
Description:	Based on observations made during the morning tour of the building, the facility failed to ensure all areas are well-ventilated and free from foul odors. EVIDENCE: 1. Resident room # 102 had a strong urine smell throughout the room. 2. Resident rooms 203 and 205 had a strong urine odor throughout the room and the adjacent bathrooms.
Plan of Correction:	Housekeeping located odors in roo 102, 203, and 205. Shampooing of carpet and deep cleaning was performed to eliminate odors on 5/8/19. Nursing staff and all other associates will be re-educated through in-service on ensuring all odors are to be reported to housekeeping team in a timely manner and also on disposal of used incontinent products after rounding. Maintenance or designee will audit building daily through rounding to ensure building is free of odor. [sic]
Standard #:	22VAC40-73-920-C
Description:	Based on observations and interviews with staff, during the tour of the building, the facility failed to maintain an operable ventilation system to the outside to eliminate odors in all resident bathrooms. EVIDENCE: 1. The overhead vent fans in the bathrooms of resident rooms 203, 205, 206, and 209 were determined to not be pulling air through the ventilation system from 10:30 ? 10:45 a.m. This determination was based on the systems inability to pull a 1/2 square of toilet tissue up to the vent grid, when placed against the vent. 2. Strong urine odors were detected in the bathrooms and resident rooms in rooms 203 and 205. 3. Maintenance staff that were interviewed reported that the system was an automatic intermittent run system. However, maintenance staff did not know the frequency of or what triggered the intermittent turn on. Maintenance staff stated that they did not know how to test the system to determine if it was working.
Plan of Correction:	Ventilation system was services by Shuler's heating and cooling and found to have a broken belt on 05/08/19. Belts were ordered and ventilation system was repaired on 05/14/19. Maintenance Director will be in-serviced on preventative maintenance and routine checks of ventilation system. [sic]