VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at the Ballentine
7211 Granby Street
Norfolk, VA 23505
(757) 440-7400

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: May 20, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This was an unannounced focused monitoring inspection conducted to follow-up on violations cited during the previous inspection. The inspection was conducted on May 20, 2019 from 1:10 PM until 5:21 PM. There were 71 residents in care. During this inspection there was a focus on medication administration and related provisions as well as buildings and grounds. A tour of the building was conducted to include the memory care unit. A review of the medication carts was conducted, physician's orders were reviewed, as well PRN (as needed) medication availability. Resident records were also reviewed. Discussions were conducted with facility staff regarding staff training and in-service on the facility's medication management policy and storage of medications, medication cart audits for expired medications, and housekeeping/maintenance procedures. Also discussed information required on the social data form, and hospice information on Individualized Service Plans (ISPs). Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice. The plan of correction should include how the violation will be or has been corrected. Just writing the word 'corrected' is not acceptable. Your plan of correction should include: 1. Step(s) to correct the non-compliance with the standard(s) 2. Methods to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative action. If you have any questions please contact your inspector at 757-353-0430.

Violations:

Standard #:	22VAC40-73-650-B
Description:	Based on record review and interview, the facility failed to ensure physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements identify the diagnosis for each drug. Evidence: 1. During review of resident records, the diagnosis was not identified for the following medications: a. Vanilla Boost for resident #1 on physician's order dated 3-22-19. b. Enoxaparin injection 30mg/0.3ml, Mirtazapine 30mg, and Refresh tears 0.5% for resident #3 on physician's order dated 3-22-19. The resident was admitted to the facility on 3-19-19. The diagnosis for the medications mentioned were also not included on the admission orders for resident #3. c. Lactobacillus tab for resident #4 on physician's order dated 5-09-19. 2. During interview, staff #1 acknowledged the missing diagnosis on the aforementioned medications.
Plan of Correction:	RCD, ARCD or designee review all new orders daily to ensure continued compliance. During review diagnosis were obtained from prescriber. Review was done on all records to ensure that all Rx's OTC identify the diagnosis condition or specific indications for administering each drug.