VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at the Eastern Shore
23610 North Street
Onancock, VA 23417
(757) 787-4343

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: June 4, 2020 and June 5, 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 22VAC40-90 The Criminal History Record Report

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 06-04-2020 and concluded on 06-05-2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 47. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 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-compliance's with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on resident record review and interview, the facility failed to ensure prior to admission to a safe, secure environment, the resident was assessed in writing by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Staff #1 provided resident #2?s ?Resident Face Sheet Profile? which documented the resident was admitted on 03-14-2020. 2. Staff ?Progress Notes? dated 05-01-2020, documented ?Resident transferred to Memory Care?? 3. Resident #2?s ?Assessment of Serious Cognitive Impairment? form was dated 06-04-2020. 4. Staff #1 could not provide additional documentation of resident #2 being assessed in writing by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare prior to admitting to the safe, secure environment on 05-01-2020. 5. Staff #1 acknowledged resident #2 was placed on the safe, secure environment prior to the resident being assessed by the physician in writing.
Plan of Correction:	What Has Been Done to Correct? On 6/6/2020, a Serious Cognitive Impairment Form was completed for Resident #2 by the in-house physician. How Will Recurrence Be Prevented? Effective on 6/4/2020, a resident will not be moved into the secure environment until a Serious Cognitive Impairment form is completed. Effective as of 6/4/2020, before each admission to the secure environment, the Resident Care Director or her designee will audit the resident?s admission paperwork for the completed Serious Cognitive Impairment form and sign off on the new resident audit sheet that this was completed. Person Responsible: Resident Care Director
Standard #:	22VAC40-73-260-A
Description:	Based on staff record review and interview, the facility failed to ensure each direct care staff member maintained current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #3 was hired as a Registered Medication Aide on 08-01-2019. Staff #1 provided a copy of staff #3?s first aid certification which was through ?Relias.? 2. Staff #1 could not provide documentation that staff #3 maintained current certification in first aid through one of the approved organizations. 3. Staff #1 acknowledged staff #3 did not maintain current certification in first aid from one of the approved organizations.
Plan of Correction:	What Has Been Done to Correct? Staff member #3 will be trained in First Aid by 7/6/2020. How Will Recurrence Be Prevented? Effective as of 6/5/2020, all staff member files were audited for completion, including First Aid and CPR certification. The Business Office Manager will audit all employee files for completion on a monthly basis and record the completion of this on the Business Office Employee File Audit Sheet. Person Responsible: Business Office Manager
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review and interview, the facility failed to ensure a person had a physical examination completed within 30 days prior to admission by an independent physician that included the required information. Evidence: 1. Resident #3?s physical examination report was dated 09-06-2019. Resident #3?s physical examination report did not include the resident?s weight, blood pressure, or general physical condition. Staff #1 did not provide additional documentation of the resident?s admission weight, blood pressure, or general physical condition as part of the physical examination. 2. Staff #1 stated ?resident #3 admitted to the facility on 12-18-2019.? Staff #1 also provided a statement from resident #3?s spouse dated 06-05-2020 which documented ?This is to verify that [resident #3] entered CSL on December 18, 2019. We reserved the room in September 2019 and paid each month but resident #3 didn?t move in until it was really needed.? 3. Staff #1 provided a copy of resident #3?s ?UAI Determination and Written Assurance? dated 12-18-2020 which documented the ?UAI of 12-19-2019 has placed this person?s care needs into the following category for admission: Special Care Unit due to diagnosis of Alzheimer?s dementia.? 4. Staff #1 acknowledged resident #3?s physical examination was not completed within 30 days prior to admission and did not include the aforementioned required information.
Plan of Correction:	What Has Been Done to Correct? Effective on 6/4/2020, each new resident?s physical exam will be completed no earlier than 30 days prior to admission. The Resident Care Director or her designee will assure prior to admission that the physical exam forms are complete and are in the required thirty day window. How Will Recurrence Be Prevented? Beginning immediately, the Resident Care Director and/or her designee will audit all new resident physical forms for completion with each new admission using an audit form which includes an audit for date of admission physical exam. Person Responsible: Resident Care Director
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 #3?s signed physician?s orders dated 04-07-2020, which documented ?Humalog Insulin VL-7510- inject subcutaneously 3 times a day with meals per SS [Sliding Scale]: ? 301-350=7U?? 2. Resident #3?s May 2020 Medication Administration Record (MAR) documented blood sugar (BS) was ?349? on 05-03-2020 when checked during the 12:00 PM medication administration; and ?310? on 05-30-2020 when checked during the 5:00 PM medication administration. 3. Staff #1 provided documentation labeled ?Blood Sugar,? which documented the number of units of Humalog insulin administered to Resident #3 for the following blood sugar readings: A. 12 units on 05-03-2020 during the 12:00 PM medication administration (for a BS of 349) and; B. 8 units on 05-30-2020 during the 5:00 PM medication administration (for a BS of 310). C. The physician?s instructions documented to administer 7 units of insulin for blood sugar readings 301 to 350. 4. Staff #1 provided a copy of resident #2?s current signed physician?s orders dated 03-12-2020 which documented ?Refresh Tears- 2 gtts Q 8 hours for dry eyes.? 5. Staff initialed resident #2?s May 2020 MAR documenting Refresh Tears were administered on 05-01-2020 through 05-31-2020 during the scheduled administration times of 9:00 AM, 1:00 PM, and 5:00 PM. The resident did not receive the Refresh Tears on 05-09-2020 during the 5:00 PM medication administration with a documented reason of ?the resident refused.? Resident #2?s Refresh Tears were administered every 4 hours, however, the physician?s instruction was every 8 hours. 6. During interview, staff #1 and staff #2 acknowledged resident #4?s Humalog insulin and resident #2?s Refresh Tears were not administered in accordance with the physician?s instructions.
Plan of Correction:	What Has Been Done to Correct? On 6/6/2020, the pharmacy for CSL Eastern Shore added a feature that will not allow an RMA or LPN to administer insulin until correct amount is entered into the system and accepted. Resident Care Director or Assistant Resident Care Director will also monitor insulin administration daily of each resident who receives insulin by sliding scale. On 6/6/2020, all staff members who administer medications were re-trained on how to properly administer the Refresh Tears for Resident #2 according to the physician?s order. How Will Recurrence Be Prevented? Effective, 6/4/2020, the RCD or her designee will audit the MAR weekly to monitor for correct administration of all medications. Effective as of 6/4/2020, the Resident Care Director or her designee will review that all new orders for medications are sent to the pharmacy per the physician?s order. Person Responsible: Resident Care Director/Assistant Resident Care Director
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review and interview, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. Staff #1 provided a list of newly hired staff and dates of hire, which included staff #5 was hired on 05-21-2019. 2. Staff #5?s ?Criminal History Record/Sex Offender and Crimes Against Minors Registry Search Form? documented the facility requested the criminal history record on 05-17-2019; however, the report did not include the results from the Virginia State Police. Staff #1 could not provide an additional criminal history record report that was obtained on or prior to the 30th day of staff #5?s employment. 3. Staff #1 stated ?We are not able to produce a criminal background report for staff #5. We have resubmitted for her report??
Plan of Correction:	What Has Been Done to Correct? On 6/4/2020, Staff Member # 5 was removed from the schedule until the Criminal Background Check was received. On 6/10/2020, the Criminal Background Check for Staff Member #5 was received. How Will Recurrence Be Prevented? Effective as of 6/6/2020, the Business Office Manager will audit all new hire paperwork for completion and sign off that all required documentation has been received using a ?New Hire Audit Sheet.? This will be completed prior to the scheduling of the new hire?s first scheduled shift. Person Responsible: Business Office Manager
Standard #:	22VAC40-90-50-B
Description:	Based on record review and interview, the operator of the facility failed to ensure that each criminal history record report was verified by matching the name to establish that all information pertaining to the individual cleared through the Central Criminal Records Exchange is exactly the same as another form of identification such as a driver's license. The operator of the facility failed to request a new criminal history record when the information did not match. Evidence: 1. Staff #1 provided a list of newly hired staff with dates of hire. Staff #6?s date of hire was 05-17-2019, staff #7?s date of hire was 06-03-2019, and staff #8?s date of hire was 08-14-2019. 2. Staff #1 provided copies of staff #6, staff #7, and staff #8 driver?s licenses. The staff persons? names as shown on the driver?s licenses did not match the names documented on the following criminal history record reports: A. Staff #6?s report dated 05-07-2019 and staff #8?s report dated 08-14-2019 did not include the correct spelling of the last names; and B. Staff #7?s report dated 06-03-2019 did not include the correct spelling of the first name. 3. Staff #1 could not provide documentation of new criminal history records with the correct names for staff #6, staff #7, or staff #8. 4. Staff #1 acknowledged staff #6, staff #7, and staff #8?s names documented on the criminal history record reports did not match the names shown on the staffs? driver?s licenses.
Plan of Correction:	What Has Been Done to Correct? On 6/4/2020, Staff #6 and #7 and #8?s Criminal Background Checks were re-submitted and received as ?clear? with the correct spelling of each staff member?s name. How Will Recurrence Be Prevented? Effective as of 6/4/2020, the Business Office Manager will assure that all potential new employee criminal history check forms will be sent with a copy of the staff member?s driver?s license so that the correct spelling of the staff member?s name can be confirmed prior to sending off the criminal background check request. In addition, the Business Office Manager will conduct bi-weekly audits of the employee files for completion. Person Responsible: Business Office Manager