VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Memory Care at Chesapeake
130 Great Bridge Boulevard
Chesapeake, VA 23320
(757) 436-2109

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: May 28, 2020 and May 29, 2020

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 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 05-28-2020 and concluded on 05-29-2020. The Resident Care Director was contacted by telephone to initiate the inspection. The Resident Care Director reported that the current census was 51. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, criminal background checks and sworn disclosures of newly hired staff, staff schedules, fire drills, fire and health inspection reports, dietary oversight, and healthcare oversight. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1130-C
Description:	Based on record review and interviews with staff, the facility failed to ensure that during night hours, when 40 or more residents are present, at least four direct care staff members plus at least one more direct care staff member for every additional 10 residents, or portion thereof should be awake and on duty at all times in each special care unit. Evidence: 1. Staff #1 provided documentation of the staff working schedule labeled ?West Schedule 2020? and ?East Schedule 2020.? The schedules documented 5 direct care staff were scheduled to work on 05-17-2020, 05-18-2020, and 05-24-2020. Staff #1 stated there were 53 residents in care on 05-17-2020, 05-18-2020, and 05-24-2020; therefore the facility was required to have 6 direct care staff on duty during night hours. 2. Staff #1 and staff #6 provided staff timecards labeled ?Time Detail Report.? The timecards reviewed did not indicate that there were at least six direct care staff members on duty at all times in the facility during the ?overnight shift? from 11:00 p.m. to 7:00 a.m.: A. Staff #6 explained the ?Time Detail Report? for the 11:00 p.m. to 7:00 a.m. shift and stated the staffs? time worked is reflected on the next date. B. The ?Time Detail Report? dated 05-18-2020 and 05-19-2020 documented 5 direct care staff (#7, #8, #9, #10, and #11) worked during the 11:00 p.m. to 7:00 a.m. shift on 05-17-2020 and 05-18-2020. Staff #1 and staff #5 could not provide ?Time Detail Reports? or documentation indicating that additional staff worked during the 11:00 p.m. to 7:00 a.m. shift. C. The ?Time Detail Report? dated 05-25-2020 documented 5 direct care staff (#2, #12, #13, #15, and #16) worked during the 11:00 p.m. to 7:00 a.m. shift on 05-17-2020 and 05-18-2020. D. Staff #1 and staff #6 could not provide ?Time Detail Reports? or documentation indicating that additional direct care staff worked during the 11:00 p.m. to 7:00 a.m. shift 05-17-2020, 05-18-2020, and 05-24-2020. 2. During interview, staff #1 was asked if the facility utilized a staffing agency and staff #1 stated ?no agency.? Staff #1 and staff #6 acknowledged that the facility did not have at least six direct care staff on duty in the facility at all times during the night hours.
Plan of Correction:	1.Census and staffing are being reviewed daily during morning stand up, to ensure compliance. 2.Daily staffing assignment sheets being utilized. 1.Census and staffing are being reviewed daily during morning stand up, to ensure compliance. ongoing Person Responsible: Executive Director, Resident Care Director and/or designee
Standard #:	22VAC40-73-450-C
Description:	Based on observation, record review, and interview, the facility failed to ensure the comprehensive Individualized Service Plan (ISP) included a description of identified needs and date identified based on the Uniform Assessment Instrument (UAI), physician?s orders, and fall risk rating. Evidence: 1. On 05-28-2020 and 05-29-2020, during resident record review, the following ISP?s did not include a description of the resident?s identified needs: A. Resident #1?s current UAI dated 07-02-2019 documented the need for mechanical and physical assistance with dressing; however, the current ISP dated 03-23-2020 did not document the type of mechanical device that is used for dressing. The current physician?s order dated 05-14-2020 for oxygen documented ?03-20-2020- Oxygen @2L as needed for short of breath;? however, the need for oxygen was not identified on the ISP. The ?Morse Fall Scale? form dated 03-10-2020 documented the resident is a ?level 3? and to implement ?high risk fall prevention interventions;? however, the ISP did not document the high risk for falls. B. Resident #3?s current UAI dated 08-30-2019 documented the need for mechanical and physical assistance with dressing; however, the current ISP dated 10-29-2019 did not include the type of mechanical device that is used for dressing. C. Resident #4?s current UAI dated 05-24-2020 documented the need for mechanical and physical assistance with dressing; however, the current ISP dated 05-24-2020 did not include the mechanical device that is used for dressing. 2. During interview on 05-28-2020 and 05-29-2020, staff #1 acknowledged resident #1, resident #3, and resident #4?s ISP?s did not include a description of the aforementioned residents? needs.
Plan of Correction:	Resident #1?s ISP has been updated to reflect the type of mechanical device used to assist with dressing. B. The order for oxygen dated 3/20/20, has been updated to reflect the use of oxygen as needed on ISP. C. Resident #1?s ISP has been updated to reflect ?high risk for falls?, and the type of interventions required for safety. Resident #2?s ISP has been updated to reflect the type of mechanical device used to assist with dressing. Resident #3?s ISP has been updated to reflect the type of mechanical device used to assist with dressing. UAI?s and ISP?s will be randomly reviewed monthly for regulatory compliance. Person responsible: Resident Care Director and Executive Director
Standard #:	22VAC40-73-640-A
Description:	Based on resident records reviewed and interview, the facility failed to implement facility's medication management plan to ensure that each resident's prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled in a timely manner to avoid missed dosages. Evidence: 1. Staff #1 provided a copy of the facility?s policy for medication management plan labeled ?Handling, Ordering, and Refilling Medications? dated 02-01-2019, documented ?All physician ordered medications will be available for the resident.? The facility?s policy for ?Medication Administration Records? dated 02-01-2019, documented ?When a physician?s order is received for a new medication, fax the order to the pharmacy, initialing and noting on the order the date and time it was faxed?? 2. Resident #2?s physician?s order dated 05-14-2020 documented ?Augmentin 875-125mg 1 tab PO BID x 5d ? cellulitis.? The May 2020 Medication Administration Record (MAR) documented the Augmentin 875-125mg was started on 05-19-2020; 5 days after the order was written. 3. Resident #4?s physician?s order dated 05-14-2020 documented ?Tums extra strength 2 tabs PO BID x 2 weeks.? The May 2020 MAR documented the Tums (Antacid 750mg) was started on 05-19-2020; 5 days after the order was written. 4. Staff did not initial and note on resident #2 or resident #4?s physician?s orders the date and time the order was faxed to the pharmacy, per the facility?s plan. 5. Staff #1 could not provide documentation from the physician physician?s orders to start the medications 5 days after the order was written. 6. During interview, staff #1 stated the ?physician was on site? on 05-14-2020 and the physician?s orders were provided to staff for resident #2 and resident #4. Staff #1 was asked to provide documentation of when the physician?s orders were sent to the pharmacy for resident #2 and resident #4. Staff #1 stated ?We are unable to locate the confirmation slip.? 7. Staff #1 acknowledged resident #2 and resident #4?s medication was not filled in a timely manner per the facility?s medication administration plan.
Plan of Correction:	Based on our plan of correction, resident #4 and # 3 Augmentin/ Tum?s extra strength was not filled within community?s medication management plan. 1. Nurse Practitioner was made aware of violations and has been assigned designated area to place all orders for processing by the RCD and ARCD. 2. Resident Care Director and/or designee currently initial, date and time all orders after being faxed to pharmacy per edication management policy. The Resident Care Director and/or designee are monitoring and managing these orders to ensure policy/regulatory compliance. Resident Care Director, Assistant Resident Care Director and /or designee will periodically check for, review, and fax all orders to pharmacy daily then monitor/manage the orders to ensure policy/regulatory compliance. 3. All faxed confirmations to be placed in a binder for 30 days, then filed away in brown envelopes after 30 days. Resident Care Director, Assistant Resident Care Director and /or designee will periodically check for, review, and fax all orders to pharmacy daily then monitor/manage the orders to ensure policy/regulatory compliance. Person Responsible: Resident Care Director, Assistant Resident Care Director and / or designee
Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview, the facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. Staff #1 provided a copy of resident #4?s signed physician?s orders (labeled ?Resident Medication Profile?) dated 05-21-2020, which documented ?HumaLOG U-100 Insulin 100 unit/mL subcutaneous solution ? Notes: Sliding Scale Insulin? Blood sugar is 150.00 ? 175.00 2 units? Frequency: Two times daily.? 2. Resident #4?s May 2020 Medication Administration Record (MAR) documented the blood sugar was ?172? on 05-24-2020 during the 7:30 AM medication administration; and ?154? on 05-25-2020 during the 7:30 AM and 4:30 PM medication administrations. Staff documented ?none? for the amount of insulin administered on 05-24-2020 and 05-25-2020. The physician?s instructions indicated 2 units of Humalog insulin to be administered for blood sugar readings of 150.00 to 175.00. 3. During interview, staff #1 and staff #2 acknowledged resident #4?s Humalog was not administered in accordance with the physician?s instructions.
Plan of Correction:	Based on record review for resident # 3?s Humalog sliding scale insulin. 1.All registered medication aides have attended a 4-hour medication refresher course which include insulin administration 2. All registered mediation aides have been assigned 2 (assisting with mediation administration, dangerous medications, each are 1 hour) additional modules of medication administration via Relias. 3. All medication aides to be signed off by Resident Care Director for sliding scale insulin administration Random medication administration records to be reviewed weekly Person Responsible: Resident Care Director, Assistant Resident Care Director 1. 4-hour refresher completed on 5/29/2020 2. Relias training completion by 6/26/2020 3. Completion of sign off for sliding scale insulin by Resident Care Director ? 6/26/2020