VIRGINIA DEPARTMENT OF SOCIAL SERVICES

COMMONWEALTH SENIOR LIVING AT GLOUCESTER HOUSE
7657 Meredith Drive
Gloucester, VA 23061
(804) 693-3116

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: May 11, 2020 , June 3, 2020 and July 15, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 complaint inspection was initiated on 05/11/2020 and concluded on 07/15/2020. A complaint was received by the department regarding allegations in the areas of PART V -ADMISSION,RETENTION AND DISCHARGE OF RESIDENTS and PART VI- RESIDENT CARE AND RELATED SERVICES. The Administrator was contacted by telephone to conduct the investigation. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. Please contact the facility Licensing Inspector, Kimberly Rodriguez at 757-586-4004 or by email at kimberly.rodriguez@dss.virginia.gov for additional questions or concerns.

Violations:

Standard #:	22VAC40-73-40-A
Complaint related:	Yes
Description:	Based on review of the facility medication management plan the facility failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state, and local laws; with other relevant regulations; and with the facility's own policies and procedures. Evidence #1: On 07/15/2020 while reviewing resident #1 medication administration records, according to the Medication Administration Record, " Exceptions for resident #1" the resident refused Imatnib Mes Tab 400 mg ordered to "take one tablet by mouth QD Cytotoxic Agent- Must wear gloves when handleing tablets DX: GI Cancer," on 3/24/2020, 03/31/2020, 04/04/2020, 04/05/2020, 04/09/2020, 04/10/2020 and Methenam Hip Tab 1GM ordered to "Take one tablet by mouth twice a day DX: Treat UTI" on 03/21/2020, 03/24/2020, 03/27/2020, 03/31/2020, 04/01/2020, 04/04/2020, 04/05/2020, 04/07/2020, 04/08/2020, 04/09/2020, 04/10/2020. Evidence #2: While reviewing the facility medication management plan on 07/29/2020, "Med48-Communication of Medication Related Issues or Observations to Physician (02/01/2019) reads, "The Resident Care Director and the resident's physican will be informaed of any medication related issues or observations." " The Med Aide who becomes aware of any medication related issues or observations will document the issue/observation on the Med Aide to Med Aide Communication Log and inform the Resident Care Director. Examples of issues or observation include, but are not limited to, refused medications, adverse medication effects, missed medication dosages, medication concerns reported by a resident, etc." "2. The Med Aide who observed the issue or observation of concern is responsible for routinely communicating issues or observations related to medications administration to the prescribing physican or other prescriber."
Plan of Correction:	In-service completed with medications aides and licensed nursing staff. The community will utilize a refusal of medication form that requires provider's signature and the completed documents will bemainatined in residents record. RCD or licensed nurse designee will review missed medications as part of the weekly cadence to ensure compliance wih physician or licensed provider being notified of refused medications.
Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on record review the facility failed to ensure each facility shall report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence:On 07/15/2020 while conducting record review for resident #1, documented on resident #1's discharge summary dated 03/20/2020 reads, " Today's Visit, Reason for Visit, Fall Diagnosis, Fall, initial encounter, contusion of rib on left side, initial encounter. This incident was not reported to to the regional licensing office within 24 hours.
Plan of Correction:	In-service completed with medication aides and licensed nursing staff. Staff to notify RCD or designee of any resident leaving via EMS or fitting other licensing reporting requirements. RCD or designee to report to ED to ensure compliance with regulation.
Standard #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	Based on record review and staff interview the facility failed to ensure the comprehensive individualized service plan included a Description of identified needs and date identified based upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources; Evidence #1: On 06/03/2020 while interviewing staff #2, staff #2 stated, " Staff would take food to resident #1's room and encourage him to eat." Evidence #2: On 07/15/2020 while conducting record review for resident #1, Assessments completed by resident #1's physician reads, 3/6/2020 " Pt is refusing meal and does not like to go to the dining room", 3/13/2020 " Staff are taking food into residents room to encourage resident to eat food resident is often refusing to go to the dining room", 3/20/2020 " Resident will occasionally eat but needs a great deal of encouragement and is not consistent with residents intake due to agitation", 3/27/2020 " Staff are trying to be resourceful on ways to encourage resident resident to eat which is resourceful at times. they are also leaving food in residents room to encourage resident to eat when there is nobody around," 4/3/2020 "Seeing pt who was previously refusing to eat but has become more adamant about not eating and more combative when approached to provide basic care". " Staff have done well at being resourceful on ways to encourage resident to eat which is successful at times. They are also leaving extra food in residents room to encourage resident to eat when there is nobody around resident and are giving medications with higher protein putting instead of water." Evidence #3: On 07/15/2020 while reviewing resident #1's "Service Plan Detail" with activation date of 12/13/2019, effective date of 12/13/2019 and last modified of 04/21/2020 reads, " Meal Consumption... Resident does not require assistance with meal consumption. Evidence #4: on 07/15/2020 while reviewing the facility progress note entry dated 04/09/2020 reads, " Weight loss-26lb weight loss noted when monthly weights were done 4/2/2 and communincation was sent to PCP. PCP started resident megestrol due to weight loss.
Plan of Correction:	In-service completed with all ISP certified associates. Audit of ISP's to ensure regulatory compliance per our policy and proceedure to be completed by ED/RCD or designee.