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: Dec. 2, 2019 and Dec. 3, 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 Inspector from the Eastern Regional Office on 12-02-2019 from 8:41 AM to 5:08 PM and on 12-03-2019 from 8:40 AM to 3:43 PM. There were 69 residents in care at the time of the inspection. A tour of the facility was conducted and water temperatures were sampled during the tour. During the inspection, breakfast and an activity on the special care unit were observed. The medication pass observation was conducted with 2 staff and 5 residents were observed. 5 staff records,10 resident records, and 1 discharge record were reviewed. Interviews were conducted with staff and residents throughout the inspection. The following documents were also reviewed: Health Care Oversight, Resident Council, Fire and Emergency Evacuation Drills, Emergency Preparedness Plan, Menus, Activity Calendars, and the Dietary Oversight. The facility's First Aid kit was also reviewed. The Criminal Background Checks and Sworn Disclosures for all new staff were reviewed since December 2018. The following was discussed with the Administrator during the inspection: Physician's orders, ISP's, staff orientation, emergency water as it relates to expiration dates, snack menu, housekeeping services, and resident council. Bed wedges were also discussed as a potential restraint on the special care unit. The facility received violations "under" Admission, Retention, and Discharge of Residents, Resident Care and Related Services, and Buildings and Grounds. The areas of noncompliance were discussed with the Administrator throughout the inspection and during the exit interview. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the Violation Notice within 10 days of today's date, 01-25-2020.

Violations:

Standard #:	22VAC40-73-430-H-1
Description:	Based on observation and interview, the facility failed to ensure at the time of discharge, the assisted living facility provided to the resident a dated statement containing the actions taken by the facility to assist the resident in the discharge and relocation process; and the resident's destination. Evidence: 1. On 12-03-2019, during resident #10?s record review with staff #1 and staff #5, the ?Discharge notification and statement? documented the resident discharged on 12-09-2019; however, the statement did not contain the actions taken by the facility to assist the resident in the discharge and relocation process or the resident?s destination. Staff #5 could not locate and/or provide documentation on file of the actions taken by the facility to assist the resident in the discharge and relocation process or the resident?s destination. 2. During interview on 12-03-2019, staff #1 and staff #5 acknowledged resident #10?s ?Discharge notification and statement? did not contain the required information, and that there was no documentation on file regarding the actions taken by the facility to assist the resident in the discharge and relocation process or the resident?s destination.
Plan of Correction:	Re-in-serviced Business Office Manager, Resident Care Director, Assistant Resident Care Director and Executive Director on DSS regulation 430 Discharge of residents. Executive Director, Resident Care Director, Business Office Manager and/or designee reviewed will review all discharges and perform persistent efforts when applicable. Executive Director and/or designee will all discharges to ensure ongoing compliance.
Standard #:	22VAC40-73-450-F
Description:	Based on observation, record review, and interview, the facility failed to ensure the Individualized Service Plan (ISP) was reviewed and updated as needed as the condition of the resident changes. Evidence: 1. On 12-02-2019, during resident record review with staff #1 and staff #2, the following ISP?s were not reviewed and updated as needed as the condition of the resident changes. A. Resident #3 had a physician?s order dated 10-07-2019 for hospice to evaluate and treat. The ?Narrative Charting? notes dated 10-18-2019 documented the resident is receiving hospice services; however, the current ISP on file dated 09-27-2019 was not updated as of 12-02-2019, to reflect the need for hospice services. B. Resident #4?s hospital discharge summary form dated 08-16-2019 documented the resident had a Foley catheter. Additionally, resident #4 was observed with a Foley catheter during the inspection; however, the current ISP on file dated 06-20-2019 was not updated as of 12-02-2019, to reflect the need for the Foley catheter. 2. During interview on 12-02-2019, staff #1 and staff #2 acknowledged resident #3 and resident #4?s ISP?s were not updated to reflect the residents aforementioned needs.
Plan of Correction:	ISP was updated to reflect resident #3 and resident #4 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 other support to ensure the individualized basic needs of the resident are adequately identified to include type of assistance needed to protect the residents health and safety. Re-in-serviced Resident Care Director and Assistant Resident Care Director on Policy GP-06 Service Plans and Assessment Updates 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, the facility failed to ensure no medication is started without a valid order from a physician. Evidence: 1. On 12-02-2019, during the morning medication pass observation, staff #4 was observed administering 1 tablet of Famatodine 20mg and 1 tablet of Ondansetron 8mg to resident #3. 2. On 12-02-2019, during resident #3?s record review with staff #1 and staff #2, the following was documented: A. The current signed physician?s order sheet on file dated 08-26-2019 documented ?Ondansetron Tab 4mg ODT- Dissolve 1 tab by mouth every 8 hours as needed for nausea/vomiting.? Additionally, the physician?s order sheet did not include a routine order for Ondansetron 8mg or for Famatodine 20mg. B. The October, November, and December 2019 Medication Administration Record documented staff administered the Famatodine 20mg tablet on 10-05-2019 through 12-02-2019, and the Ondansetron 8mg ODT Tablet on 10-04-2019 through 12-02-2019. C. Staff #2 could not locate and/or provide a valid physician?s order on file for the routine Famatodine 20mg tablet or Ondansetron 8mg ODT tablet. 3. During interview on 12-02-2019, staff #1 and staff #2 acknowledged the facility started resident #3?s Famatodine 20mg tablet and Ondansetron 8mg ODT tablets without a valid order from the physician.
Plan of Correction:	Resident #3 received a signed order from the physician for the Famotidine 20mg tablet and Ondansetron 8mg ODT tablet. All nurses and RMAs were re-in-serviced on Policy Med-03 Medication Services. 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.
Standard #:	22VAC40-73-660-B
Description:	Based on observation, record review, and interview, the facility failed to ensure the 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. On 12-02-2019, during the morning medication pass with staff #3, a bottle of ?Tums? was observed on the dresser, and a bottle of ?Tylenol? was observed on the nightstand in resident #1?s room. The bottle of ?Tums? and bottle of ?Tylenol? contained pills in each bottle and was not sealed. 2. Resident #1?s UAI dated 11-02-2019 documented medications are to be administered by a lay person. The UAI did not document that the resident could self-administer ?Tums? or ?Tylenol?. 3. During interview on 12-02-2019, staff #1 acknowledged resident #1 was not permitted to keep the ?Tums? and ?Tylenol? in the room per the UAI dated 11-02-2019.
Plan of Correction:	Medications were removed from resident #1 room and secured in the medication cart. All nurses and RMAs were re-in-serviced on Policy Med-07 Medication Storage. Executive Director, Resident Care Director or designee will conduct a random room check minimum of 2 times per month to ensure medications are properly stored for all residents who are not permitted to self-administer medications.
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. On 12-02-2019, during resident #3?s record review with staff #1 and staff #2, the following was documented: A. The current physician?s order on file dated 08-26-2019 documented ?Sertraline Tab 50mg- Take 1.5 Tab = 75mg by mouth at bedtime for depression.? B. The October 2019 Medication Administration Record (MAR) documented ?Sertraline Tab 50mg- ?Suspended 03 Oct 2019 to 07 Oct 2019: Hold per POA request until nausea had passed and [resident] is eating/drinking adequately.? The MAR documented the Sertraline 50mg tablet was not administered by staff on 10-04-2019 through 10-06-2019. C. Staff #2 could not locate and/or provide a physician?s order to hold the Sertraline 50mg tablet from 10-04-2019 through 10-06-2019. Additionally, staff #2 could not locate and/or provide documentation of the physician being notified that the resident?s Sertraline 50mg tablet was held by staff from 10-04-2019 through 10-06-2019. D. During interview on 12-02-2019, staff #1 and staff #2 acknowledged resident #3?s Sertraline 50mg tablet was not administered in accordance with the physician?s instructions. 2. On 12-02-2019, during the morning medication pass observation, resident #1?s December 2019 MAR was reviewed and documented ?Aspirin low chw 81mg- chew 1 tablet by mouth every day for CAD.? At approximately 8:57 AM, staff #3 was observed administering resident #1?s medications to include 1 tab of Aspirin low chw 81mg. Resident #1 was observed swallowing the Aspirin with the other medications. 3. On 12-02-2019, during resident #1?s record review with staff #1, the current physician?s orders on file dated 10-25-2019 documented ?Aspirin Low Chw 81mg- chew 1 tablet by mouth every day for CAD.? Resident #1 did not chew the Aspirin Low Chw 81mg tablet in accordance with the physician?s instructions. 4. On 12-02-2019, during the morning mediation pass observation, at approximately 9:20 AM, staff #3 was observed administering resident #11?s medications in a plastic pill cup. 5. On 12-02-2019, during resident #11?s record review with staff #1, the current physician?s orders on file dated 08-05-2019 documented ?Pour meds into glass container 30 minutes prior to administration due to plastic allergy.? Resident #11?s medications were not poured into a glass container during the morning medication pass observation per the physician?s orders. 6. During interview on 12-02-2019, staff #1 and staff #3 acknowledged resident #1 did not chew the Aspirin 81mg tablet and resident #11?s medications were not placed in a glass container during the morning medication pass observations.
Plan of Correction:	All nurses and RMAs were re-in-serviced on Policy Med-03 Medication Services, physician orders and Policy Med-18 Hold Orders. 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.
Standard #:	22VAC40-73-870-E
Description:	Based on observation and interview, the facility failed to ensure all toilets are kept clean. Evidence: 1. On 12-02-2019, during the tour of the facility with staff #1, a brown substance was observed on the rim of the toilet in room #145, and on the exterior portion of the toilet in room #250. In addition, there was a brown substance on the interior rim of a toilet frame located over the toilet in room #134. 2. During interview on 12-02-2019, staff #1 acknowledged the brown substance located on the aforementioned toilets and toilet frame.
Plan of Correction:	Cleaned the commodes in room 134, 145, and 250. Re-in-serviced RCA, Maintenance Director and Housekeeping Associates on DSS regulation 870-E. Executive Director, Maintenance Director or designee to will continue to round in the community minimum 2 times per day to ensure continued compliance.