VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at King's Grant House
440 North Lynnhaven Road
Va. beach, VA 23452
(757) 431-8825

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: May 3, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced monitoring inspection was conducted by the Licensing Inspector from the Eastern Regional Office on 05-03-2019 from 8:10 AM to 2:53 PM. There were 66 residents in care at the time of the inspection. A tour of the special care unit was conducted and a medication pass was completed with 4 residents. 5 resident records were reviewed and interviews were conducted. The following was discussed with the Administrator: ensuring resident records are organized to include all physician's orders, ISP's, and window locks on the special care unit. The facility received violations "under" Resident Care and Related Services. The violations were reviewed with Administrator throughout the inspection. Please complete the -Plan of Correction- for each violation cited on the violation notice and return it to me within 10 calendar days from today, on 05-30-2019. You will need to specify how the violation will be or has been corrected. Just writing the word corrected is not acceptable. Your plan of correction must include: 1. steps to correct the noncompliance 2. measures to prevent reoccurrences 3. person(s) responsible for implementing and monitoring each step of the corrective measures and / or the preventative measure.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the resident?s needs. Evidence: 1. On 04-12-2019, the Licensing Inspector (LI) received a 7 day incident report from the facility regarding an elopement on the memory care neighborhood involving resident #1. The date and time of the incident was 04-07-2019 at 3:00 PM. 2. During resident #1?s record review with staff #1 and staff #2, the current Uniform Assessment Instrument on file dated 03-27-2019 indicated the resident has wandering/passive behaviors weekly or more. In addition, LI observed physician visit notes which stated the following: a. The noted dated 03-01-2019 stated ?Patient has been admitted to the dementia unit here as he is unable to care for himself and there is a risk he would wander and he would be a danger to himself.? b. The note dated 04-17-2019 stated ?Since the patient was last seen, he did elope. He apparently had planned the elopement quite well?. According to the staff, he appears to be planning another elopement.? 3. Upon further review of resident #1?s record, the current ISP dated 03-25-2019 did not reflect the resident?s wandering behaviors. 4. During interview, staff #1 and staff #2 acknowledged resident #1?s wandering behaviors were not addressed on the ISP dated 03-25-2019.
Plan of Correction:	ISP was updated to reflect resident #1 current assessed needs. Records reviewed to include identified need and what type of assistance staff are to provide to include coordinated services, basic needs identified, and signature of legal representative. Community will continue to complete Preliminary ISP and Comprehensive ISP in conjunction with resident, family, and/or caregivers while using the History and Physical, physician orders, UAI, and other support to ensure the individualized basic needs of the resident are adequately identified to include type of assistance needed to protect the resident?s health and safety. Re-educated Resident Care Director and Assistant Resident Care Director to include all assessed needs and coordinated services on the ISP. Executive Director will review the Preliminary ISP on the date of admission. Executive Director, Resident Care Director, and/or designee reviewed other ISPs to ensure compliance. Executive Director will complete random monthly audit of a minimum of 7 Comprehensive ISPs to ensure ongoing compliance.
Standard #:	22VAC40-73-650-A
Description:	Based on record review and interview, no medication should be changed 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 morning medication pass observation, the Licensing Inspector (LI) observed staff #3 administering 1 tab of Spironolactone 25 mg to resident #2. 2. During resident #2?s record review with staff #1 and staff #2, LI observed the following: a. The resident had a current physician?s order on file dated 04-16-2018 for ?Spironolactone 50mg- Take 1 tablet by mouth every day for Hypertension.? b. Staff #2 provided LI with a physician?s order sheet dated 02-28-2019 which indicated for the resident to receive 1 tab of Spironolactone 25mg; however, the order was not signed by a physician. In addition, staff #2 faxed the order to the physician on 03-01-2019; however, as of 05-03-2019 the facility had not received a signed order for the Spironolactone 25mg tablet. c. In addition, the resident?s February, March, and April 2019 Medication Administration Record (MAR) revealed the resident has been receiving the Spironolactone 25mg tablet instead of the Spironolactone 50mg tablet. 3. During interview, staff #1 and staff #2 acknowledged there were no signed physician?s orders on file for resident #2?s Spironolactone 25mg tablet. 4. During the morning medication pass observation with staff #3, at 8:55 AM LI observed staff #3 administering 1 the following 9:00 AM medications to resident #5: Furosemide 20mg, Sertraline 50mg, Losartan 50mg, Vesicare 10mg, Memantine 28mg, and Vitamin D2 5,000 units. 5. During resident #5?s record review with staff #1 and staff #2, LI observed the following: a. The resident had a current physician?s order on file dated 08-30-2018 for ?Polyethylene gly pwd (527gm). Mix 17 gm (Capful) in 4-8 oz of liquid and give by mouth one time a day for constipation. Schedule daily at 09:00.? LI did not observed staff #3 administering the Polyethylene gly pwd (527gm) to resident #5 during the medication pass observation. b. The Polyethylene gly pwd (527gm) was not listed on the resident?s March, April, or May 2019 MAR. c. LI and staff #2 were unable to locate a discontinued order on file for the Polyethylene glycol powder (527gm). 6. During interview, staff #2 indicated resident #5?s Polyethylene glyl pwd (527gm) was discontinued by the pharmacy, and acknowledged the medication was not discontinued by the physician.
Plan of Correction:	Resident #2 received signed order from physician and Resident #5 orders updated. Re-in-serviced Resident Care Director and Assistant Resident Care Director on Verification & Clarification of Orders policy MD 09 and Medication Orders policy MD40. Resident Care Director or designee will conduct a random chart audit to include verification of orders a minimum of 4 times per month to ensure ongoing compliance.
Standard #:	22VAC40-73-650-C
Description:	Based on record review and interview, the facility failed to ensure the physician's or other prescriber's oral orders are reviewed and signed by a physician or other prescriber within 14 days. Evidence: 1. During resident #2?s record review with staff #1 and staff #2, the Licensing Inspector observed a telephone order dated 04-10-2019 for ?Clarification Diclofenac Sodium 1% gel apply 2 GM to B knees four times daily for pain.? This telephone order did not contain a signature from the physician or prescriber. 2. During interview, staff #2 confirmed the facility did not obtain a signature from resident #2?s physician regarding the aforementioned telephone order dated 04-10-2019.
Plan of Correction:	Obtained signed order from physician for resident #2. Re-in-serviced all LPN?s and RMA?s on Medication Orders policy MD 40. Resident Care Director or designee will conduct a random chart audit to include verification of orders a minimum of 4 times per month to ensure ongoing compliance.
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 morning medication pass observation with staff #3, the Licensing Inspector (LI) observed staff #3 administering resident #2?s medications, to include 1 tab of Carvedilol 25mg and 1 tab of Colesevelam 625mg. Food was not given to resident #2 during the medication administration. 2. During resident #2?s record review with staff #1 and staff #2, the resident had a current physician?s on file dated 04-16-2018 for ?Carvedilol f/c 25mg- Take 1 tab by mouth twice daily with food? and ?Welchol (also known as Colesevelam) 625mg tablet- Take 1 tab by mouth three times daily with meals.? 3. During interview, staff #1 and staff #2 acknowledged staff #3 did not administer resident #2?s Carvedilol 25mg or Colesevelam 625mg with food during the medication pass.
Plan of Correction:	All nurses and RMAs were re-in-serviced on the importance of medications being administered in accordance with the physician orders and Board of Nursing Standard of Practice. Resident Care Director or designee will conduct a random medication pass audit a minimum of 2 times per month to ensure ongoing compliance and provide any necessary coaching on medication administration concerns.