VIRGINIA DEPARTMENT OF SOCIAL SERVICES

COMMONWEALTH SENIOR LIVING AT GLOUCESTER HOUSE
7657 Meredith Drive
Gloucester, VA 23061
(804) 693-3116

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: May 21, 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:

An unannounced monitoring inspection was conducted by two Licensing Inspectors from the Eastern Regional Office on 05-21-2019 from 8:18 AM to 6:42 PM. There were 61 residents in care at the time of the inspection. A tour of the facility was conducted, water temperatures were sampled, an activity and lunch were observed. A medication pass observation was conducted on the special care unit and on the assisted living unit. 8 resident records and 4 staff records were reviewed. The Criminal Background Checks and Sworn Disclosures were reviewed for all new hires since the previous renewal inspection. Interviews were also conducted with staff and residents. LI reviewed the following: First Aid kits, menus, activity calendars, emergency preparedness exercises, fire drills, resident council, and staff schedules. The following was discussed with the Administrator during the inspection: health care oversight, 02 and therapy orders, ensuring Home Health/Hospice documentation is on file to monitor services provided to the residents, side rails, TB screening-protocol established with physician, copy of letter kept at facility, staff training for specialized needs such as foley catheter, ISP's regarding the date identified and ensuring potential behavior triggers are identified if known, and staff schedules. The facility received violations "under" Resident Care and Related Services, and Emergency Preparedness. The areas of noncompliance were discussed with the Administrator throughout the inspection and during the exit interview. 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 06-20-2019. 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 #:	22VAC40-73-440-D
Description:	Based on record review and interview, the assisted living facility failed to ensure that the uniform assessment instrument (UAI) was completed as required by 22VAC30-110. Evidence: 1. During resident record review, resident #6?s UAI dated 05-05-2019 and resident #10?s UAI dated 04-18-2019 was missing a signature from the assessor who completed the UAI. 2. During interview, staff #1 acknowledged the aforementioned UAI?s were not signed by the assessor.
Plan of Correction:	What Has Been Done to Correct? All UAIs were signed by both the assessor and the Administrator or designee on 5/21. How Will Recurrence Be Prevented? Upon completion of the UAI, the assessor will immediately sign the document and then immediately provide to the Administrator or designee for their corresponding signature Person Responsible: ED, RCD, or designee
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 residents? identified needs. Evidence: 1. During resident #9?s record review, the current ISP dated 05-15-2019 indicated the resident has a private sitter from 4:00 PM- 8:30 PM. In addition, a Private duty agency ?Assessment and Care Plan? form indicated the following services would be provided: assistance with ambulation and transfer, bathing, continence, dressing and grooming, eating, and toileting. The ISP did not include the aforementioned services being provided by the private duty sitter. 2. During resident #8?s record review, the resident has a physician?s order dated 04-10-2019 for oxygen 2 liters via nasal cannula, as needed. The current ISP dated 01-17-2019 indicated the ?resident is able to self-administer oxygen as ordered by physician?. However during interview, staff #2 indicated that facility staff ensures the oxygen is set at the appropriate concentration when in use by resident. The ISP did not include a description of the oxygen liters, route, and frequency. 3. During interview, staff #1 and staff #2 acknowledged resident #9's ISP did not identify the services provided by the private duty sitter and resident #8?s ISP did not include of the oxygen liters, route, and frequency.
Plan of Correction:	What Has Been Done to Correct? The Care Plans identified by the Licensing Inspector have been updated with the correct information. How Will Recurrence Be Prevented? A monthly care plan audit will be completed to ensure that the ISP contains a description of all of the resident?s identified needs. Additionally, upon every 6 month re-assessment or change in condition the care plan will be audited for correct information Person Responsible: ED, RCD, or designee
Standard #:	22VAC40-73-450-D
Description:	Based on record review and interview, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization should communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the Individualized Service Plan (ISP). Evidence: 1. During resident #8?s record review, the current ISP on file dated 01-17-2019 indicated the resident is on hospice. The ISP indicated "community will provide services in conjunction with the hospice care plan.? In addition, the "Hospice Initial Certification of Illness" form provided by staff #8 revealed the resident started hospice services on 01-29-2019; to include an aide, nurse, chaplain, and social worker; however, the ISP did not identify the services to be provided by hospice. 2. During review of resident #10?s record, the current ISP dated 10-18-2018 indicated the resident is on hospice. The interventions indicated the "Community will provide services in conjunction with hospice care plan", but did not indicate the services to be provided by hospice, to include an RN for wound care, a social worker, chaplain and an aide as documented on the residents Hospice plan of care report dated 05-15-2019. 3. During interview, staff #1 acknowledged the aforementioned ISPs did not include a description of the services provided by hospice.
Plan of Correction:	What Has Been Done to Correct? The Care Plans identified by the Licensing Inspector have been updated with the correct information. How Will Recurrence Be Prevented? A monthly care plan audit will be completed to ensure that the ISP contains the agreed upon coordinated plan of care with the Hospice company. Additionally, upon every 6 month re-assessment or change in condition the care plan will be audited for correct information Person Responsible: ED, RCD, or designee
Standard #:	22VAC40-73-490-A-2
Description:	Based on record review and interview, the facility failed to ensure for residents who meet the criteria for assisted living care, the licensed health care professional, practicing within the scope of their profession, should provide health care oversight at least every three months. Evidence: 1. Staff #1 provided a copy of the most current healthcare oversight which was provided by an outside agency. The healthcare oversight had a beginning date of 10-01-2018 and a completion date of 04-01-2019. There was no documentation of a healthcare oversight being provided in January 2019. 2. During interview, staff #1 confirmed the person who completed the aforementioned healthcare oversight was not on site fulltime and worked for an outside agency. Staff #1 acknowledged the facility did not have a health care oversight provided at least every three months.
Plan of Correction:	What Has Been Done to Correct? A Healthcare Oversight was completed on the community on 4/1/2019. ED received clarification on the frequency of the healthcare oversight required at the community How Will Recurrence Be Prevented? ED will reach out to neighboring CSL communities a month in advance to schedule the required quarterly Healthcare Oversight. If the community uses a current staff member/LPN of the community team to complete the Healthcare Oversight it will be completed every 6 months. Person Responsible: ED or designee
Standard #:	22VAC40-73-650-A
Description:	Based on observation, record review, and interview, the facility failed to ensure no medications are started by the facility without a valid order from a physician or other prescriber. Evidence: 1. At 9:10 AM, during the medication pass observation on the assisted living unit, staff #3 was observed administering medications to resident #2, to include 2 tabs of Hydralazine 50mg. 2. During resident #2?s record review with staff #2, the current physician?s order dated 04-12-2019 did not include an order for Hydralazine 50mg. In addition, the May 2019 Medication Administration Record revealed the resident received 2 tablets of Hydralazine 50mg at 9:00 AM on 05-01-2019 through 05-21-2019, and at 5:00 PM on 05-01-2019 through 05-20-2019. Staff #2 was unable to locate and/or provide an order for the Hydralazine 50mg. 3. During interview, staff #2 confirmed the facility did not have a physician?s order for resident #2?s Hydralazine 50mg.
Plan of Correction:	The medication referenced (Hydralazine 50mg) was prescribed to the resident (resident #2) in 2017. The original order was located in the thinned chart that had been filed away and was not provided to the inspector on 5/21/19. However, the current chart provides copies of doctor?s visits that confirm the resident was still taking Hydralazine 50mg. We located the original order dated 12/5/2017, along with an updated order dated 1/30/2018, and a copy of a doctor?s visit notes dated 2/19/2019 that confirm the resident was still prescribed the medication in question. On the date of inspection, the Licensing Inspector did not accept the doctor?s visit notes as valid because there was no physician signature.
Standard #:	22VAC40-73-650-B
Description:	Based on record review and interview, the facility failed to ensure the physician?s or other prescriber?s orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements included the diagnosis for each drug. Evidence: 1. During resident record review, the current physician's orders on file did not include a diagnosis for the following medications: a. Resident #9's physician's order dated 04-08-2019 for Alfuzosin 10mg, Almitriptyline 10mg, Hydroxyzine 25mg, Melatonin 500mg, and Quetiapine 25mg. b. Resident #8?s physician's order dated 04-05-2019 for Glipizide 5mg, Lisinopril 5mg, and Midodrine 5mg. c. Resident #3?s physician?s order dated 10-08-2018 for Polycarbophil (Fibercon) 6235mg. This was the most current order on file for this medication. d. Resident #1?s physician?s order dated 04-18-2019 for Furosemide 20mg. 2. During interview, staff #1 acknowledged the missing diagnoses on the aforementioned physician's orders.
Plan of Correction:	What Has Been Done to Correct? RCD and ARCD will review all current medications through QuickMAR and reconcile missing diagnoses with prescriber as needed. How Will Recurrence Be Prevented? Going forward all new orders will be reviewed to ensure a diagnosis is identified Person Responsible: RCD or designee
Standard #:	22VAC40-73-660-B
Description:	Based on observation, record review, and interview, the facility failed to ensure a resident was permitted to keep their own medication in an out-of-sight place in their room if the Uniform Assessment Instrument (UAI) has indicated that the resident is capable of self-administering medication. Evidence: 1. During the tour of the facility with staff #1, a tube of triad hydrophilic wound dressing was observed on resident #8?s bathroom vanity; and a bottle of saline nasal spray and cough drops were observed on resident #7?s night stand. 2. During resident record review with staff #1, resident #7's current UAI dated 04-19-2019 and resident #8's current UAI dated 01-15-2019, indicated medications are to be administered by a lay person and professional nursing staff. In addition, resident #7's current physician?s order on file dated 04-22-2019 and resident #8's current physician?s order on file dated 04-05-2019 did not indicate the residents could self-administer the aforementioned medications. 3. During interview, staff #1 acknowledged resident #7 and resident #8 were not permitted to keep the aforementioned medications in their room based on the UAI, and confirmed there were no physician?s orders on file indicating the residents were able to self-administer the aforementioned medications.
Plan of Correction:	What Has Been Done to Correct? Medications were confiscated from residents that did not have an order to self-administer on the inspection date of 5/21 How Will Recurrence Be Prevented? Room checks will be completed to ensure resident?s that do not have orders to self-administer will not have any medications in their rooms. Self-administer orders will be obtained if/when the resident requests to self-administer. All staff will be educated on observance of unsecured medications and will report any concerns to RCD/ED if identified. Person Responsible: ED, RCD, or designee
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 or other prescriber's instructions. Evidence: 1. During the medication pass observation on the special care unit, staff #4 was observed crushing resident #4?s medications and placing the medications in applesauce. At 8:45 AM, staff #4 administered the crushed Januvia 100mg, Loratidine 10mg, Metformin 500mg, Quetiapine 25mg, and Sertraline 50mg to resident #4. 2. During resident #4?s record review with staff #2, the current physician?s order on file dated 04-15-2019 did not include an order for the resident?s medications to be crushed. Staff #2 and staff #8 were unable to locate and/or provide a crushed order for resident #4. 3. At 9:00 AM, during the medication pass observation on the assisted living unit, staff #3 was observed administering medications to resident #3, to include a sublingual Vitamin B-12 1,000 mcg tab. The medications were placed on top of resident #3?s tongue. 4. During resident #3?s record review with staff #2, a current physician?s order dated 05-15-2019 for ?Vitamin B-12 SL Tab, 1,000mg- 1 tablet by mouth/sublingually one time a day for Vitamin B12 Deficiency? was observed. 5. During interview, staff #3 acknowledged resident #3?s Vitamin B-12 1,000 mcg tab was not administered sublingually.
Plan of Correction:	What Has Been Done to Correct? All RMAs will be formally re-educated on our policies and procedures regarding dispensing medications per physician?s orders. How Will Recurrence Be Prevented? Weekly medication pass audits will be completed to monitor the adherence to physician?s orders. Person Responsible: ED, RCD, or designee
Standard #:	22VAC40-73-980-G
Description:	Based on observation and interview, the facility failed to maintain a 48-hour supply of emergency drinking water on site. Evidence: 1. During review of the facility?s emergency water supply with staff #7, the facility had 24 cases of one (1 ) gallon water bottles. Each case contained three (3) gallon water bottles to equal a total of 72 gallons of water. 2. During interview, staff #7 indicated the total number of residents in care on the day of the inspection was 61, which required the facility to have a supply of 122 gallons of emergency drinking water. Staff #7 confirmed there was no other emergency water on site and acknowledged the facility did not have the required 48 hour supply of drinking water for 61 residents.
Plan of Correction:	What has been done to correct? Additional water was purchased on 5/21/2019 and delivered to the community on 5/23/2019 How Will Recurrent Be Prevented? Monthly Emergency Supply checks will be conducted to ensure the proper amount of water is on hand at all times Person Responsible: ED, DSD, or designee