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 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 22VAC40-90 The Criminal History Record Report

Comments:

This was an unannounced renewal inspection conducted by two Licensing Inspectors from the Eastern Regional Office. The inspection was conducted from 9:34 AM until 8:00 PM on May 8, 2019. There were 60 residents in care. During the inspection, a tour of the building and grounds was conducted. A medication observation was conducted on both the Assisted Living and memory care unit, as well as check of the medication carts. Meals and activities were observed. Resident records and staff records were reviewed, to include criminal background reports for all new staff since the previous inspection. Resident and family interviews were conducted. A review of the facility's emergency preparedness supplies was also conducted. The permanent memory care unit is currently under construction. The following was discussed with the Administrator, Resident Care Director, and Assistant Resident Care Director: ISP training for staff; Annual direct care staff training to include infection control, mental impairments, and be relevant to the population in care; Snacks posted on menus; Activities calendar; Physician's orders; and annual fire inspection. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice. The plan of correction must indicate how the violation will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction should include: 1. Steps to correct the noncompliance 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative actions. If you have any questions please contact your inspector, Reyna Rios at (757) 353-0430.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on observation, record review and interview, the facility failed to ensure prior to admission to a safe, secure environment, the resident was assessed by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. During the medication pass observation, the Licensing Inspector observed resident #6 receiving medications on the ?Sweet Memories? memory care unit. 2. During resident #6's record review, resident #6 was admitted to the ?Sweet Memories? memory care unit on 03-05-2019. The ?Assessment of Serious Cognitive Impairment? form dated 03-01-2019 asked ?Does the individual named above have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia? Is the individual named above unable to recognize danger or protect his/her own safety and welfare?? Both of these questions were checked ?no?. 3. During interview, staff #1 acknowledged resident #6's assessment by an independent physician did not indicate the resident has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Plan of Correction:	The Resident Care Director or Assistant Resident Care Director will assure that each resident in Memory Care who is assessed as having a serious cognitive decline due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare, will have that assessment prior to admission to our Memory Care environment. In addition, the Resident Care Director or Assistant Resident Care Director will assure that all resident Assessment of Serious Cognitive Impairment Forms in Sweet Memories will be audited for the appropriate "yes" response on the Assessment of Serious Cognitive Impairment form prior to admission and all current forms will be audited for correctness. The Resident Care Director will create this audit form. Resident #6's Assessment of Serious Cognitive Impairment form now reflects a "yes" on the questions which indicate a Serious Cognitive Impairment.
Standard #:	22VAC40-73-210-E
Description:	Based on record review and interview, the facility failed to ensure staff receive training relevant to the population in care provided by a qualified individual through in-service training programs or institutes, workshops, classes, or conferences. Evidence: 1. During resident #6's record review, the Licensing Inspector (LI) observed a fax to the physician dated 03-24-2019 which stated "Resident got a skin tear to left upper arm and right leg while transferring on hoyer lift. I would like an order to apply protective sleeves to both arms and legs?? 2. During resident #5's record review , the current Individualized Service Plan dated 04-19-2019 indicated the resident is a two person assist and uses a hoyer lift. 3. During interview, staff #2 was unable to provide LI with documentation to verify that direct care staff received training on hoyer lifts and also confirmed that the staff have not received hoyer lift training.
Plan of Correction:	All associates who use the Hoyer lift were re-educated on using the Hoyer lift safely. In addition, yearly associate Hoyer lift training will be conducted by the Resident Care Director or Assistant Resident Care Director or an appropriate outside provider as an ongoing standard practice. New associates will also be trained on proper usage of the Hoyer lift, prior to using it. All training will be documented by the Resident Care Director or Assistant Resident Care Director on an ongoing basis and training logs will be audited each quarter for completeness.
Standard #:	22VAC40-73-450-A
Description:	Based on record review and interview, the facility failed to ensure that on or within seven days prior to the day of admission a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. A preliminary plan of care is not necessary if a comprehensive individualized service plan (ISP) is developed on the day of admission. Evidence: 1. During review of resident records, the following resident records did not contain a preliminary plan of care or a comprehensive ISP completed on or within 7 days prior to the day of resident's admission to the facility: a. Resident #3, admitted on 12-14-2018. b. Resident #4, admitted on 12-14-2018. c. Resident #8, admitted on 12-14-2018 d. Resident #9, admitted on 02-04-2019. 2. During interview, staff #2 and staff #3 confirmed resident #8 and resident #9 did not have a preliminary plan of care or a comprehensive ISP on file. Staff #2 also acknowledged resident #3 and #4 did not have a preliminary plan of care on file and stated a comprehensive ISP was not completed at the time of admission.
Plan of Correction:	The Resident Care Director or Assistant Resident Care Director will assure that the Preliminary Plans of Care will be completed on or within 7 days prior to the day of resident's admission to the facility. ISP training will be completed by consulting group for Resident Care Director and Assistant Resident Care Director by 6/20/19. Individualized Service Plans have been completed for Residents #3, #4, #8, #9 by staff nurse who has ISP training. Once trained, an audit of all ISPs will be conducted monthly by the Resident Care Director or Assistant Resident Care Director to ensure that all ISPs are comprehensive and complete. Until trained, the audits will be conducted by the nurse who is ISP trained or by the consulting nurse who is also ISP trained.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview, the facility failed to ensure the comprehensive Individualized Service Plan (ISP) include a description of the resident's needs. Evidence: 1. During review of resident #2's record, the resident was admitted on 02-05-2019. Licensing Inspector (LI) observed a visit note in the record dated 02-18-2019 documenting a physical therapy visit. The note indicated physical therapy would occur two times per week for "gait, balance, and strength". The most recent physical therapy visit note in the resident's record was dated 05-06-2019. a. Resident #2's comprehensive ISP dated 02-20-2019, did not include a description of the resident's need for physical therapy. In addition, the resident's ISP indicated the resident has a Do not Resuscitate (DNR) order. However; review of the resident's file indicated the resident was listed as "Full Code" on the Personal/Social Data form and had a form dated 02-05-2019 signed by the resident indicating she is a "Full Code". Resident #2's record did not have a DNR order on file. Further review of the resident's record revealed the Uniform Assessment Instrument (UAI) dated 02-20-2019 indicated the resident needs mechanical and human help with bathing. However, the ISP stated "allow resident sufficient time to bathe without feelings of being rushed", but did not include a description of the mechanical device needed to assist the resident or the physical assistance to be provided by staff. 2. During resident #5's record review with staff #2, the current Uniform Assessment Instrument (UAI) dated 04-19-2019 indicated the resident needs human help with physical assistance with bathing and toileting. The current ISP dated 04-19-2019 did not include a description of how the staff will physically assist the resident with bathing and toileting. 3. During resident #6's record review with staff #2, the current UAI dated 03-28-2019 indicated the resident needs human help with physical assistance with bathing and mechanical and human physical assistance with toileting and transferring. The current ISP printed on 03-25-2019 did not include a description of how the staff will physically assist the resident with bathing, and the type of mechanical device needed for toileting and transferring was not identified. In addition, a physician?s noted dated 03-12-2019 indicated the reason for the appointment was for ?Hospice Admission;? however, the ISP did not reflect hospice services being provided. 4. During interview, staff #2 acknowledged resident #2's need for physical therapy services and that resident #2 does not have a DNR. In addition, staff #2 acknowledged the aforementioned needs were not identified on resident #5 and resident #6's ISP?s.
Plan of Correction:	The Resident Care Director or the Assistant Resident Care Director will assure that all Individualized Service Plans will include complete descriptions of resident needs. Resident #2's Individualized Service Plan now includes a description of the resident's need for physical therapy. In addition, the Resident #2's Full Code status was clarified with both resident and POA. Resident #5's Individualized Service Plan now includes a description of how the staff physically assists the resident with bathing and toileting. Resident #6's Individualized Services Plan will include a description of how the staff will physically assist the resident with bathing and the type of mechanical device needed for toileting and transferring. In addition, this resident's Individualized Service Plan now reflects that the resident is receiving Hospice services. A monthly ISP audit will be conducted by the ISP trained nurse to ensure that resdient needs are being addressed and exactly how they are being addressed. When the Resident Care Director and Assistant Resident Care Director are ISP trained, one of the two will do the monthly ISP audit to verify that needs are being addressed and how they are being addressed, using an ISP audit form that will be developed for this purpose.
Standard #:	22VAC40-73-450-E
Description:	Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) was signed and dated by the administrator or the designee and by the resident or the legal representative. These requirements shall also apply to reviews and updates of the plan. Evidence: 1. During resident #6 record review, the preliminary ISP dated 03-05-2019 and the comprehensive ISP dated 03-25-2019 were missing a signature from the administrator or the designee and from the resident or the legal representative. 2. During resident #7's record review, the resident?s ISP was updated on 02-13-2019 to reflect skilled nursing services for wound care; however, the ISP was missing a signature from the administrator or the designee and from the resident or the legal representative. 3. During interview, staff #2 and staff #3 acknowledged resident #6 and resident #7's aforementioned ISP?s were not signed and dated by the administrator or the designee and by the resident or the legal representative.
Plan of Correction:	An ISP audit will be conducted by the Resident Care Director assuring that all Individualized Service Plans are properly signed and dated by the administrator or designee and by the resident or legal representative-both for admission ISPs and for reviews and updates of the plan. Resident #6's preliminary and comprehensive ISPs have been signed by the designee and the resident's legal representative. Resident #7's ISP was properly signed by both the designee and the resident's legal representative. As part of the ISP monthly audit, the Resident Care Director or Assistant Resident Care Director will assure that signatures have been obtained.
Standard #:	22VAC40-73-650-A
Description:	Based on observation, record review, and interview, the facility failed to ensure no medication or diet was started or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications. Evidence: 1. During the inspection, staff #1 provided the Licensing Inspector (LI) with a list of residents who are receiving a special diet; to include resident #7 whose diet was listed as ?Puree w/thickened liquids?. 2. During the lunch observation, LI observed resident #7 eating the following pureed foods: carrots, mashed potatoes, and country steak. LI also observed resident #7 drinking thickened water. 3. During resident #7's record review with staff #3, the nurse?s notes dated 04-15-2019 stated ?Resident came back from hospital about 2:30pm. Came back with new orders, on 2 liters of oxygen continuously. Pureed diet, honey thickened liquids?? 4. Upon further review of resident #7's record with staff #3, the facility?s ?Dietary Communication Notification? form dated 04-15-2019 indicated there was a change in the residents diet and that the resident required a pureed diet with thickened liquids. The Dietary Communication form did not include a signature from the resident?s physician. In addition, LI and staff #3 were unable to locate a signed physician?s order on file to indicate the resident should receive a pureed with thickened liquid diet. 5. During interview, staff #3 confirmed the facility did not have a signed valid order on file for resident #7 to receive a pureed with thickened liquid diet. 6. During resident #8's record review with staff #2, the resident had a physician?s order dated 02-08-2019 for ?Afrin- spray around nostril (Lt) if nose starts to bleed and apply pressure.? The Afrin was listed as PRN on the February 2019 Medication Administration Record (MAR); however, the medication was not listed on the March, April, or May 2019 MAR. 7. During review of the medication cart located on the Assisted Living Unit with staff #8, LI and staff #8 were unable to locate resident #8's Afrin on the cart. Staff #8's indicated she believed the medication was discontinued back in March. 8. Upon further review of resident #8's record with staff #2, LI and staff #2 were unable to locate a discontinued order on file for resident #8's Afrin. 9. During interview, staff #2 confirmed there was no discontinued order on file for resident #8's Afrin.
Plan of Correction:	The Resident Care Director or Assistant Resident Care Director will assure that all medications and diets will not be started or discontinued by the facility without a valid order from a physician or other prescriber. Resident #7 and Resident #8 orders were clarified by the physician on 5/14/2019. The Resident Care Director or Assistant Resident Care Director will audit physician's orders weekly to verify that resident medications and diets have not been started or discontinued without the valid order. The Resident Care Director or Assistant Resident Care Director will create an audit form for all orders and will verify these orders weekly on the audit form.
Standard #:	22VAC40-73-650-F
Description:	Based on record review and interview, the facility failed to ensure whenever a resident is admitted to a hospital for treatment of any condition, the facility should obtain new orders for all medications and treatments prior to or at the time of the resident's return to the facility. The facility should ensure that the primary physician is aware of all medication orders and has documented any contact with the physician regarding the new orders. Evidence: 1. During resident #7's record review with staff #2, the hospital discharge summary dated 04-15-2019, revealed the resident was admitted to the hospital on 04-12-2019 and discharged on 04-15-2019. The hospital discharge summary stated ?Resident #7 was found to have a right upper lobe pneumonia? After discussion with the family they elected hospice care? Resident #7 will be discharged to CSL with Levofloxacin and Clindamycin. Resident #7 will need 2 l NC oxygen.? The Licensing Inspector and staff #2 were unable to locate documentation on file to verify the facility had contacted resident #7's physician prior to or at the time of the resident's return to the facility. 2. Upon further review of resident #7's record, the resident was not previously receiving hospice care, oxygen, Levofloxacin or Clindamycin. 3. During interview, staff #2 confirmed the facility did not notify resident #7's physician regarding the new orders that were given during the hospital visit dated 04-12-2019 through 04-15-2019.
Plan of Correction:	The Resident Care Director or the Assistant Resident Care Director will assure that new orders will be obtained for all medications and treatments prior to or at the time a resident returns to the facility after a hospital stay. This will be verified in the resident's record and on the ISP. In addition, the primary physician will be notified of all medication orders by the Resident Care Director or Assistant Resident Care Director or their designee who will documented any contact wit the physician regarding new orders. Resident #7's physician has been notified of resident's condition since returning to the community from the hospital. In addition, the physician has been notified of the change in orders from the hospital and the fact that the resident is now receiving Hospice services.
Standard #:	22VAC40-73-660-B
Description:	Based on observation, record review, and interview, the facility failed to ensure when a resident keeps their own medication in their room, the Uniform Assessment Instrument (UAI) indicates that the resident is capable of self-administering medication. Evidence: 1. During the tour of the facility, the Licensing Inspector observed the following: a. In resident #10's room, there was a bottle of Tums located on top of the resident?s dresser, and a bottle of Tylenol located in an unzipped toiletry kit in the resident?s bathroom. During interview, the resident stated staff assist with medication administration. b. In resident #8's room, there was a bottle of Waltussin DM located on top of the resident?s dresser. 2. During resident record review with staff #2, resident #10's current UAI dated 01-25-2019 and resident #8's current UAI dated 03-26-2019 indicated for medications to be administered by a lay person and professional nursing staff. 3. During interview, staff #2 indicated there were no orders on file for resident #10 and #8 to self-administer their medications. Staff #2 acknowledged resident #10 and #8 were not permitted to keep medications in their room.
Plan of Correction:	When a resident who is capable of self-administering medications has medications in his/her room, the Resident Care Director or Assistant Resident Care Director will assure that the UAI reflects that they are capable of self-administering medications. The Resident Care Director met with #10's family and they have been educated about not bringing in medications and understands that the resident's UAI states that a lay person or professional nursing staff member must administer the medication. Resident #8's family has also been educated about not bringing in medications and understands that the UAI states that a lay person or professional nursing staff member must administer medications. In addition, the Resident Care Director or Executive Director will send a letter to all family members of current and future residents regarding bringing in medications, based on the DSS regulation and Commonwealth Senior Living policy.
Standard #:	22VAC40-73-680-D
Description:	Based on observation, record review, and interview, 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. During the medication pass observation with staff #5, the Licensing Inspector (LI) observed staff #5 crush resident #6's Acetaminophen 325mg tablet and resident #7's Depakoke 125mg tablet and Carbidopa 25/100 half tablet. LI then observed staff #5 administering the crushed medications to resident #6 at 12:04 PM and to resident #7 at 12:34 PM. 2. During resident record review with staff #2 and staff #3, resident #6's current physician?s order dated 03-26-2019 did not include an order to crush medications. Resident #7's current physician?s order dated 01-08-2019 had a question on the order which stated ?Resident?s current medications require crushing?? which was checked ?no?. 3. During the inspection, staff #2 provided LI with a telephone order for resident #6 dated 05-08-2019, which stated ?Please give consent to crush.? 4. During interview, staff #2 and staff #3 acknowledged there was no crush order on file for resident #6 or resident #7's medications, and acknowledged the aforementioned medications were not administered in accordance with resident #6 and resident #7's physician?s instructions.
Plan of Correction:	The Resident Care Director or Assistant Resident Care Director will assure that all medications will be administered in accordance with physician's orders by reviewing physician's orders weekly. RMA associates will be in-serviced and re-educated by the Resident Care Director or Assistant Resident Care Director on the instructions and standards or practice outlined in the current registered medication aide curriculum. One on One training will be held with the RMA who crushed the medications for Resident's #6 and #7 has been held by the Resident Care Director.
Standard #:	22VAC40-73-680-G
Description:	Based on record review and interview, the facility failed to ensure over-the-counter medications were labeled with the resident's name. Evidence: 1. During a check of the assisted living medication cart with staff #4, the following over-the-counter medications were not labeled with the resident's name: a. Ocuvite soft gels and Caltrate 600 +D3 for resident #11. b. Aspirin 81mg for resident #12. 2. During interview, staff #4 identified the Ocuvite and Caltrate 600 belonged to resident #11 and the Aspirin 81 mg belonged to resident #12. Staff #4 acknowledged the aforementioned medications were not labeled with the residents' name.
Plan of Correction:	The Resident Care Director or Assistant Resident Care Director will assure that all over the counter medications will be labeled with the resident's name prior to being placed in the medication cart. Resident #11 and Resident #12 medications were labeled with their names and placed in the medication cart. The Resident Care Director or Assistant Resident Care Director will do a weekly audit of the medication cart to make sure that all medications are properly labeled. An audit form will be developed by the Resident Care Director or Assistant Resident Care Director and signed off on a weekly basis.
Standard #:	22VAC40-73-700-2
Description:	Based on observation, record review, and interview, the facility failed to post a "No Smoking-Oxygen in Use" sign in a room where oxygen was in use. Evidence: 1. During the tour of the memory care unit at 9:45 AM, Licensing Inspector (LI) observed the resident in room C-4 with an oxygen concentrator on and in use. LI did not observe an "Oxygen in Use" sign in the resident's room or outside of the resident's room door. During review of resident #4's record, LI observed a "standing order" from hospice for oxygen via nasal cannula. 2. LI informed staff #1, #2, and #3 who acknowledged the missing sign in resident #4's room.
Plan of Correction:	The Resident Care Director or Assistant Resident Care Director will assure that when a resident has an order for oxygen, they will also have a sign "Oxygen in Use" on their door or inside the resident's room. The Resident Care Director will conduct a monthly audit to assure that proper signs are in place for those receiving oxygen. Resident #4 now has an "Oxygen in Use" sign.