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: July 15, 2020 , July 16, 2020 and July 17, 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 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 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 07-15-2020 and concluded on 07-17-2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 55. 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 #:	22VAC40-73-450-C
Description:	Based on resident record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the resident?s identified needs based on the Uniform Assessment Instrument (UAI) and physician?s orders. Evidence: 1. Resident #2?s physician?s order dated 04-18-2020 documented ?02 @2L/NC prn- SOB [shortness of breath].? 2. Resident #2?s current ISP dated 05-08-2020 documented ?Oxygen- Administer oxygen PRN for shortness of breath?? The ISP did not include the oxygen liter flow or route. In addition, the resident?s current UAI dated 04-02-2020 documented the need for mechanical and physical assistance with toileting; however, the ISP did not include the type of mechanical device needed for toileting. 3. During interview, staff #1 and staff #2 acknowledged the resident?s current ISP did not include a description of the resident?s aforementioned identified needs.
Plan of Correction:	ISP was updated to reflect residents current assessed needs. Re-in-serviced Resident Care Director and Assistant Resident Care Director on including all assessed needs on the ISP. All ISP?s were audited to ensure they reflected the residents current assessed needs. Executive director or designee will audit a minimum of 7 resident UAI?s and ISP?s per month to ensure accuracy of assessed needs for continued compliance.
Standard #:	22VAC40-73-680-E
Description:	Based on resident record review and interview, the facility failed to ensure medical treatments ordered by a physician are provided according to his instructions and documented. The documentation should be maintained in the resident's record. Evidence: 1. Resident #2?s hospice physician?s orders dated 06-19-2020 documented ?2 LPM [liters per minute] via nasal cannula continuous for shortness of breath/dyspnea.? The current signed hospice ?Plan of Care? physician?s orders dated 07-01-2020 documented ?Oxygen- Wear oxygen 2LPM via NC continuously. Start: 06-19-2020.? 2. Resident #2?s June and July 2020 Medication Administration Records (MAR?s) documented ?Oxygen- 2 liters via N/C for SOB.? The MAR?s did not document that the resident received 2 liters of oxygen continuously on 06-19-2020 through 07-15-2020. In addition, staff #2 could not provide documentation verifying staff administered 2 liters of continuous oxygen to resident #2. 3. Staff #1 provided a copy of the written agreement between the facility and hospice program proving care to resident #2 and the facility?s ?Hospice (02/012019)? policy. A. The written agreement documented ?Agency shall ensure that all Agency Personnel have been provided orientation and training by Facility regarding Facility policies and procedures before and Agency Personnel member begins providing Agency Services?. Agency shall immediately report the occurrence of any of the following to the Facility liaison and the Facility?s Resident Care Director by telephone and thereafter promptly in writing? any change in condition of a Resident that could require a change in the nature of Facility Services to be provided to a Resident.? B. The facility?s hospice policy documented ?The hospice nurse should document any significant change? The Outside Agency Services Documentation form may be used to keep the Resident Care Director informed of visits, resident status, and changes in condition.? 4. Staff #2 stated the hospice did not provide documentation of resident #2?s oxygen orders until the day of the inspection on 07-16-2020. 5. Staff #1 and staff #2 acknowledged the facility did not provide resident #2?s oxygen in accordance with the physician?s instructions.
Plan of Correction:	Resident #2 MAR and ISP updated to reflect the current physician order. All nurses and RMAs were re-in-serviced on Hospice Policy CL05. Resident Care Director and or designee will review the hospice plan of care and hospice will utilize our Outside Agency/Services documentation form to keep the Resident Care Director informed on any change of condition to ensure ongoing compliance.