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: Jan. 7, 2020 , Jan. 8, 2020 and Jan. 9, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 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 on January 7, 2020 from 9:24 am until 5:45 pm, January 8, 2020 from 9:37 am until 5:11 pm, and January 9, 2020 from 10:15 am until 4:00 pm. There were 64 residents in care. The new Executive Director was present. During the inspection, a tour of the building and grounds was conducted, a medication administration was observed in the assisted living and safe, secure unit. The medication cart, resident records and staff records were reviewed. Criminal background checks for all new staff hired since the last renewal inspection were also reviewed. The facility's emergency supplies were reviewed. During the inspection, there was discussion regarding the health care oversight time frames and qualified who are able to provide the oversight. The process for verifying required information for private duty staff from a licensed home care agency, physician signatures, cognitive impairment training for staff, and psychotropic treatment plans were discussed. There was a discussion regarding the new Individualized Service Plan (ISP) system and staff schedules. The areas of non-compliance 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. The plan of correction must indicate how the violation will be or has been corrected. Your plan of correction should include: 1. Step(s) to correct the non-compliance 2. Measures to prevent re-occurrence; and 3. Person(s) responsible for implementing each step and/or monitoring any preventive action(s). The plan of correction is due within 10 calendar days on or before 2/15/2020.

Violations:

Standard #:	22VAC40-73-310-D
Description:	Based on record review and interview, the facility failed to provide written assurance to the resident documenting that the facility has the appropriate license to meet their care needs at the time of admission. A copy signed by the resident or his legal representative was not in the resident's record. Evidence: 1. On 1-07-2020 copies of the written assurances were not in the following records: a. resident #2 who was admitted on 11-29-19; b. resident #3 who was admitted on 12-31-19; c. resident #5 who was admitted on 4-26-19; and d. resident #9 who was admitted on 9-19-19. 2. During interview, staff #1 and staff #4 acknowledged the aforementioned residents did not have a signed written assurance in the record at the time of inspection.
Plan of Correction:	Resident # 2, 3, 5, and 9 pre-admission information was documented. All other resident records were checked to make sure the pre-admission interview was documented. Executive Director, Resident Care Director, or designee will ensure all pre-admission information is obtained and documented prior to admission. Executive Director or designee will audit a minimum of 5 resident files per month to ensure ongoing compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview, the facility failed to ensure the comprehensive Individualized Service Plan (ISP) include a description of the resident's identified needs based upon the Uniform Assessment Instrument (UAI) and other other sources. Evidence: 1. Resident #1's ISP dated 10-10-19 documented that the resident needs mechanical and human help for dressing. The mechanical device was not documented. The ISP also documented that the resident needs oxygen, however the ISP did not document the route, concentration, or duration. 2. Resident #4 has a Guardian appointed on 4-21-16. Resident #4's ISP dated 12-7-19 did not document the resident's need for a Guardian. 3. Resident #6 has services with the PACT Team. Staff #2 stated the PACT Team visits the resident approximately 3 times per week to monitor medications and behaviors. The services were not reflected on resident #6's ISP dated 12-14-19. 4. Resident #7 has a private sitter that sits for approximately 4-5 hours per day. The need for a sitter, the frequency of services, and the description of services provided by the sitter were not reflected on the ISP dated 10-21-2019.
Plan of Correction:	Resident #1, 4, and 7 ISP?s was updated to reflect residents current assessed needs. The Resident Care Director or designee will ensure that each ISP is reviewed and updated annually or if there is a change in the resident condition. The ISPs of other residents were reviewed to ensure compliance. Records reviewed to include identified need and what type of assistance staff are to provide to include coordinated services, basic needs identified, and signature of legal representative. Community will continue to complete Preliminary ISP and Comprehensive ISP in conjunction with resident, family, and/or caregivers while using the History and Physical, physician orders, UAI, and other support to ensure the individualized basic needs of the resident are adequately identified to include type of assistance needed to protect the resident?s health, safety, type of assistance required by coordinated services if applicable, and required signatures. Executive Director will review the Preliminary ISP on the date of admission. Executive Director or designee will complete random monthly audit of a minimum of 5 Comprehensive ISPs per month to ensure ongoing compliance.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, record review and interview, the facility failed to implement the medication management plan to include: methods to ensure that each resident's prescription medications ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: 1. Resident #1's physician's order dated 12-10-2019 for Combigan sol 0.2/0.5% eye drops and Pot [Potassium] Chloride Tab 20MEQ were scheduled to be administered at 9 am. a. On 1-7-2020 during the medication pass observation with staff #5 at 9:30 am, resident # 1's Potassium Chloride tab was not in the medication cart. Staff #5 stated resident #1's Potassium Chloride was not in the facility and had been ordered from the pharmacy. b. Review of the December 2019 MAR, documented the Combigan sol 0.2/0.5% was not administered to resident #1 for five (5) days. Documented as the reason for not administering the medication was "awaiting pharmacy" on the following days: 12-16-19 at 5 pm, 12-17-19 at 5 pm, 12-18-19 at 9 am, 12-19-19 at 9 am and 5 pm. 2. The facility's medication management plan indicates under the section "Handling, Ordering, and Refilling Medications" that the facility will re-order medications for twice a day medications when medications are "at the number 10 on last used blister pack", and for scheduled liquids, such as eye drops, "count the number of ml needed for 5 days and approximate your ordering". The plan also indicates "please allow 5 days for refills".
Plan of Correction:	Resident Care Director followed up with all Responsible Parties and Physicians for Resident #1, 2, 3, and 5 to report missing doses of medications. All nurses and RMAs re-educated on the medication management policy regarding refilling medications to ensure medications are refiled timely to avoid missed dosing. Executive Director, Resident Care Director, or designee will ensure adherence to the medication management policy. Random monitoring of compliance will be completed a minimum of 1 time per week by the Executive Director, Resident Care Director, or designee to ensure continued compliance. Resident Care Director, Assistant Resident Care Director, or designee will monitor medication administration records a minimum of 1 time per day to monitor medication administration and medication cart audits a minimum of 2 times per month to ensure compliance.
Standard #:	22VAC40-73-650-A
Description:	Based on record review and interview, the facility failed to ensure no treatment was discontinued by the facility without a valid order from a physician or other prescriber. Evidence: 1. Resident #5 had a physician's order dated 11-20-19 for Hydrocortizone cream to be administered for two (2) weeks. The November 2019 MAR documented that the medication was not administered due to "waiting on pharmacy" from 11-21-19 through 11-22-19. The MAR documented that the medication was not started or administered to the resident for the remainder of the month. The Hydrocortizone cream was not documented on the December 2019 MAR. Staff #2 and staff #3 were unable to provide a physician's order to discontinue the Hydrocortizone cream. 2. Staff #2 acknowledged there was no order to discontinue the Hydrocortizone cream and that the cream was not administered to the resident as ordered.
Plan of Correction:	All nurses and RMAs were re-inserviced on the importance of ensuring that no medications are started, stopped, or changed by the facility without a valid order from a physician. All medication administration orders were checked to ensure that a valid physicians order was present and that the prescribed medications were available in the medication cart to ensure compliance. Licensed Nurse will continue to review all new medication orders in the Electronic Medication Administration Record and compare them to the physician?s order and diagnosis prior to approving medication for administration and discontinuation orders will continue to be sent to pharmacy to discontinue active medication orders to ensure ongoing compliance. Resident Care Director, Assistant Resident Care Director, or designee will complete monthly cart and chart audits to ensure no medication is started or discontinued by facility without a valid order from a physician or prescriber. Resident Care Director, Assistant Resident Care Director, or designee will complete weekly med pass audit to ensure ongoing compliance with administration of medications and documentation.
Standard #:	22VAC40-73-950-E
Description:	Based on record review and interview, the facility failed to conduct a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers. Evidence: 1. The last documented semi-annual review of the emergency preparedness and response plan was dated 1-16-19. The facility was unable to provide documentation that a review was conducted after 1-16-19 with all staff, residents, and volunteers. 2. Staff #1 acknowledged there was no documentation of the emergency preparedness and response plan review after 1-16-19.
Plan of Correction:	Executive Director re-educated on the frequency requirement for the semi-annual review of emergency preparedness and response plan. Executive Director will keep documentation of the semi-annual review with required documentation details. Executive Director will review the monthly log of required reviews and trainings on the 25th of every month to ensure ongoing compliance.
Standard #:	22VAC40-73-970-A
Description:	Based on record review and interview, the facility failed to ensure the fire drills required each month were conducted in each shift for the quarter. Evidence: 1. During review of the Fire and Emergency Evacuation Drill reports, no drill was conducted during the 11 pm -7 am shift from 9-2019 to 12-2019. The last documented drill conducted on the 11 pm -7 am shift was on 7-30-19 at 5:45 am. 2. Staff #1 acknowledged the fire drills were not conducted on the 11 pm- 7 am shift from 9-2019 through 12-2019.
Plan of Correction:	Executive Director re-educated the Maintenance Director on the frequency requirement of fire and emergency evacuation drills in accordance with the Virginia Statewide Fire Prevention Code and the required documentation. Maintenance Director will keep the log of fire and evacuation drills with required documentation details. Executive Director will review the monthly log of the drills on the 25th of every month to ensure ongoing compliance.
Standard #:	22VAC40-73-990-B
Description:	Based on record review and interview, the facility failed to ensure the procedures in the plan for resident emergencies were reviewed by the facility at least every six months with all staff. Evidence: 1. The last documented review of the resident emergencies with all staff was dated 1-16-2019. 2. Staff #1 acknowledged the facility did not have a documented review completed after 1-16-19.
Plan of Correction:	Executive Director re-educated on the frequency requirement for associate review of the procedures in the resident emergency plan. Executive Director will keep documentation of the semi-annual review with required documentation details. Executive Director will review the monthly log of required reviews and trainings on the 25th of every month to ensure ongoing compliance.