VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Georgian Manor
651 River Walk Parkway
Chesapeake, VA 23320
(757) 436-9618

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Sept. 20, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

An unannounced monitoring inspection to investigate self-reported incidents was conducted by two Licensing Inspectors on September 20, 2019 from 9:07 a.m. to 1:27 p.m. There were 68 residents in care. The following was discussed during the inspection: staff communication log from shift to shift and labeling medications outside of the container. Please submit your ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it within 10 calendar days. The plan of correction must indicate how the violation will be or has been corrected. The plan of correction must include: 1. Step(s) to correct the noncompliance with the standard(s) 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative measures. If you have any questions, please contact your inspector Alexandra Poulter at 757-613-5133 or alexandra.poulter@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-660-B
Description:	Based on record review and interview, the facility failed to ensure a resident may be permitted to keep their own medication in an out-of-sight place in his room if the Uniform Assessment Instrument (UAI) has indicated that the resident is capable of self-administering medication. Evidence: 1. Resident #2 admitted on 09-04-18. The resident?s UAI dated 04-04-19 documents the resident?s medications are ?Administered by lay person/professional nursing staff.? 2. During a tour of the facility on 09-20-19, resident #2?s bathroom contained a bottle of Extra Strength Pain Relief on the counter. 3. Staff #1 observed and confirmed the bottle of Extra Strength Pain Relief located in resident #2?s bathroom.
Plan of Correction:	Medications were removed from the residents? room. Executive Director provided notification to residents and responsible parties reminding them of requirements for self-administration of medications and storage of medications. Resident care Director to re-educate Nurses, RMAs, and Resident Care Associates on reporting and addressing any concerns with unapproved self-administration or storage of self-administration medications when identified. RMA will check the residents? suite daily to ensure proper storage of the medications for residents with self-administration and keep at bedside medication orders. Resident Care Director or designee will conduct random audits of the resident?s suite to ensure continued compliance.
Standard #:	22VAC40-73-680-I
Description:	Based on record review and interview, the facility failed to ensure the Medication Administration Record (MAR) included any medication errors. Evidence: 1. An incident report received on 09-14-19 documented: ?RMA reported to the RCD that she administered the incorrect medications to resident [resident #1]. RMA stated resident was administered carbidopa/levodopa 25/100mg (2 tabs); correct dosage is 25/100 (1 ? tabs).? The documented date and time of the incident was 09-14-19 at 9:00 a.m. 2. Review of resident #1 September 2019 MAR revealed the MAR did not include the medication error regarding the incorrect number of carbidopa/levodopa 25/100mg tabs that were administered to the resident on 09-14-19. 3. During interview, staff #1 and staff #2 observed and confirmed the medication error was not included on resident #1 September 2019 MAR.
Plan of Correction:	Resident Care Director to educate Nurses and RMAs on required medication error documentation in accordance with DSS standards and BON standards. Resident Care Director or designee will review all medication errors to ensure required documentation is present for ongoing compliance.
Standard #:	22VAC40-73-700-2
Description:	Based on observation, record review, and interview, the facility failed to ensure the ?No-Smoking- Oxygen in Use? sign was posted in any room where oxygen is in use. Evidence: 1. During a tour of the Safe, Secure Environment (SSE), resident #3 had oxygen tanks visible in the room. 2. Review of resident #3?s record documented an order dated 08-06-19 for oxygen: ?O2 @2LPM via nasal cannula prn comfort.? 3. Staff #1 observed and confirmed the oxygen observed in resident #3?s room and the resident?s order to receive oxygen.
Plan of Correction:	No Smoking-oxygen In Use sign was placed on the room door. Resident Care Director to re-educate RMAs and Nurses that when oxygen order is received that the required postings must be in place. Resident Care Director or designee will conduct random audits to ensure conintued compliance a minimum of 2 times per week.
Standard #:	22VAC40-73-860-I
Description:	Based on observation and interview, the facility failed to store cleaning supplies and other hazardous materials in a locked area. Evidence: 1. During the tour of with staff #1, the following cleaning supplies and hazardous materials were observed, left unattended and in an unlocked area near rooms #46 and #47: A. The door to the emergency supply storage room was open and contained 7 bottles of Crystal Odor Protein and 1 bottle of Resolve carpet cleaner. B. A mini-refrigerator located in the hallway contained 1 bottle of Crystal Odor Protein and 1 bottle of Bac-cide placed on top. C. The maintenance closet located directly adjacent from the emergency supply storage room was open and contained approximately 15 cans of paint, wires, pesticides and insect killer, and various tools. 2. Room 45 was left open with maintenance supplies inside to include a toolbox, two cans of paint and other painting materials. 3. Staff #1 and staff #3 observed and confirmed the aforementioned cleaning supplies and other hazardous materials were not stored in a locked area.
Plan of Correction:	All housekeeping chemicals and maintenance supplies were secured in a locked cabinet. Maintenance Director and Housekeeping Associates were re-educated on the requirement to store cleaning supplies and other hazardous materials in a locked cabinet. Executive Director will continue to round in the community a minimum of 2 times per day and Program Director will round in the memory care neighborhood a multiple times throughout the day to ensure continued compliance.