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: June 27, 2018 and June 28, 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 renewal inspection was conducted by the Licensing Inspectors from the Eastern Regional Office on 06-27-2019 from 10:11 AM to 5:11 PM and on 06-28-2019 from 6:14 AM to 12:31 PM. There were 64 residents in care at the time of the inspection. A tour of the facility was conducted, water temperatures were sampled, and an activity and lunch were observed. A medication pass observation was conducted 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 monitoring inspection. Interviews were also conducted with staff and residents. LI reviewed the following: menus, activity calendars, resident council, and staff schedules. The first aid kit was reviewed for the facility, however, the first aid kit on the van was not available for review due to the van being serviced at a shop. The following was discussed with the Administrator during the inspection: side rails, physician's orders, respite paperwork re: re-admissions, wound documentation by the physician and stages of wounds, medication refresher training, and the accessibility of air diffusers on the memory care unit. The facility received violations "under" Admission, Retention, and Discharge of Residents, and Resident Care and Related Services. 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 07-20-2019. 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 #:	22VAC40-73-320-B
Description:	Based on record review and interview, the facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. On 06-27-2019, during resident #6?s record review with staff #1, the resident admitted to the facility on 02-15-2014. The current TB screening on file was dated 12-05-2017. Staff #1 was unable to locate an annual TB screening on file for resident #6. 2. During interview on 06-27-2019, staff #1 acknowledged an annual TB screening was not completed for resident #6.
Plan of Correction:	What Has Been Done to Correct? The community reached out to the PCP to obtain an updated TB test for this resident. How Will Recurrence Be Prevented? A weekly chart audit will be conducted to ensure all residents are up-to-date on their TB tests Person Responsible: ED, RCD, or designee
Standard #:	22VAC40-73-350-A
Description:	Based on record review and interview, the facility failed to ascertain prior to admission whether a resident was a registered sex offender. Evidence: 1. On 06-27-2019, during resident record review with staff #1, the following sex offender screenings did not include the correct name of the resident: a. Resident #2 admitted to the facility on 05-29-2019. The sex offender screening dated 05-29-2019 documented the resident?s last name as the first name, and the first name as the last name. b. Resident #5 admitted to the facility on 06-14-2019. The sex offender screening dated 06-12-2019 documented the resident?s last name as the first name, and the first name as the last name. 2. Additionally, resident #1 admitted to the facility for respite care on 04-22-2019 and discharged home on 05-01-2019. The resident was re-admitted for respite care on 06-05-2019, however, the facility did not ascertain a new sex offender screening prior to the admission date of 06-05-2019. 3. During interview on 06-27-2019, staff #1 was unable to provide an additional sex offender screening with the correct names of the resident's and acknowledged that the facility did not ascertain a new sex offender screening for residents' #1, #2, or #5 prior to admitting to the facility.
Plan of Correction:	What Has Been Done to Correct? Sex offender searches were re-run on both residents on June 27th and June 28th How Will Recurrence Be Prevented? Going forward all Sex Offender searches will be audited before the resident?s admission into the community to ensure compliance Person Responsible: ED 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 resident?s identified needs. Evidence: 1. On 06-27-2019, during resident record review with staff #1 the following ISP?s did not include a description of the resident?s identified needs: a. Resident #2?s current Uniform Assessment Instrument (UAI) dated 05-28-2019 documented the resident?s need for physical and mechanical assistance with bathing and dressing; however, the current ISP on file dated 05-28-2019 did not include the type of mechanical device needed for bathing and dressing. b. Resident #5?s current UAI dated 06-12-2019 documented the resident?s need for physical and mechanical assistance with bathing, dressing, and toileting; however, the current ISP on file dated 06-12-2019 did not include the type of mechanical device needed for bathing, dressing, or toileting. c. The April, May, and June 2019 ?Narrative Charting? documented resident #6 is receiving Home Health services for wound care and PTINR?s; however, the current ISP dated 06-06-2019 did not include a description of the resident?s need for Home Health services. 2. During interview on 06-27-2019, staff #1 acknowledged the aforementioned needs were not identified on resident #2, resident #5, or resident #6?s ISP?s.
Plan of Correction:	What Has Been Done to Correct? The ISPs were corrected to include mechanical devices needed for dressing, bathing and toileting, as well as to include specific services required for the resident related to Home Health. How Will Recurrence Be Prevented? Monthly chart audits will be completed to ensure continued compliance with making sure all required services for each resident are listed clearly in the ISP Person Responsible: ED, RCD, or designee
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. On 06-28-2019, during resident #9?s record review with staff #1 and staff #2, the current physician's order dated 05-21-2019 did not identify a diagnosis for the following medications: Albuterol HFA Inhaler, Bumetanide 0.5mg, Bumetanide 1mg, Citalopram 10mg, Digoxin 0.125mg, Florastor 250mg, Nitroglycerin Patch 0.2mg/hr, Optichamber Diamond, Pantoprazole 40mg, Potassium Cl Er 40mg, Potassium CL ER 10meq, Ranitidine 150mg, Tylenol Arthritis ER 650mg, and Vitamin C 1,000mg. 2. On 06-28-2019, during review of resident #10?s current physician's order dated 04-05-2019 with staff #1 and staff #2, the order did not identify a diagnosis for the following medications: Aspirin EC 81mg, Fexofenadine 180mg, Humalog Insulin 100U/ML, Insulin Levemir 100U/ML, Levothyroxine 150mcg, and Acetaminophen 325mg. 3. During interview staff #1 and staff #2 acknowledged the missing diagnoses on resident #9 and resident #10?s aforementioned physician's orders.
Plan of Correction:	What Has Been Done to Correct? All diagnoses have been updated in our system and the RCD and ARCD have been instructed to ensure all POSs are faxed to their respective physicians to obtain signatures. How Will Recurrence Be Prevented? Going forward the RCD and ARCD will ensure diagnoses are entered at the time that we receive an order. The ED will perform chart audits to look specifically for diagnoses listed on the POS on a weekly basis to ensure continued compliance. Person Responsible: ED, 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) indicated that the resident is capable of self-administering medication. Evidence: 1. On 06-28-2019, during the morning medication pass observation with staff #6, the following medications were observed on resident #12?s nightstand: 1 bottle of Pilocarpine Hydrochloride Opthamolic Solution and 1 Symbicort inhaler. 2. During resident #12?s record review with staff #1 on 06-28-2019, the current UAI on file dated 06-03-2019 documented medications are to be administered by a lay person/professional nursing staff, and also documented that the resident is disoriented to some spheres some of the time. In addition, the current physician?s orders on file dated 06-06-2019 did not document that the resident is able to self-administer the aforementioned medications. 3. During interview on 06-28-2019, staff #1 acknowledged resident #12 was not permitted to keep medications in the room based on the aforementioned UAI, and confirmed there were no physician?s orders on file indicating the resident was capable of self-administer the aforementioned medications.
Plan of Correction:	What Has Been Done to Correct? The RMA responsible will receive a corrective action for not following policies and procedures to personally administer all medications unless ordered by the physician that the resident can self-administer. The RMA instead left the medication in the resident?s room for her to self-administer instead of following protocol. How Will Recurrence Be Prevented? All RMAs will be re-in-serviced on the importance of not allowing residents to keep items in their room that are medicated, unless they have a physician?s order on file to be able to self-administer. Weekly medication pass audits will be conducted to ensure continued compliance. 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 were administered in accordance with the physician?s instructions. Evidence: 1. On 06-28-2019, during the morning medication pass observation, resident #13?s June 2019 Medication Administration Record documented the Metformin 500mg is to be administered in the morning with breakfast. At 6:52 AM, staff #6 was observed administering 1 tab of Metformin 500mg to resident #13 without food; in the resident?s room. When asked if resident #13 had eaten breakfast, the resident stated ?no, breakfast is at 8:00 AM.? 2. On 06-28-2019, at 8:16 AM, resident #13 was observed sitting at the dining room table waiting for breakfast to be served. Additionally, a sign was posted outside of the dining room documenting the time of breakfast is from 8:15 AM to 9:15 AM. 3. During resident #13?s record review with staff #1 on 06-28-2019, the current physician?s order on file dated 04-09-2019 documented ?Metformin tab 500mg- 1 tablet by mouth one time a day in the morning with breakfast.? 4. During interview on 06-28-2019, staff #1 and staff #6 acknowledged resident #13?s Metformin 500mg tab was not administered in accordance with the physician?s instructions.
Plan of Correction:	What Has Been Done to Correct? The RMA on duty that did not follow physician?s orders will receive a corrective action for not following policies and procedures and administering a medication outside of the physician?s prescribed orders. The RMA was in-serviced on this same topic on 6/17/19 during our all-staff meeting. Additionally, resident # 13?s Metformin 500mg was changed to be administered at 8am, closer to the time that the resident eats his breakfast. How Will Recurrence Be Prevented? All RMAs will be re-in serviced on the importance of administering medications in accordance with physician?s orders. Weekly medication pass observations will be conducted to ensure continued compliance Person Responsible: ED, RCD, or designee