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: Dec. 31, 2020 , Jan. 11, 2021 and Jan. 12, 2021

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 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 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 complaint investigation was initiated on 12-31-2020 and concluded on 01-12-2021. A complaint was received by the department regarding allegations in the areas of Staffing and Supervision, Physical examination and report, Physician?s or other prescriber?s order, Administration of medications and related provisions, Personal Care Services and General Supervision of Care, Individualized Service Plans, Provisions for signaling and call systems, Storage of Medications, and Fall risk rating. The Resident Care Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Resident Care Director a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations 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.

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on record review and interview, the facility failed to report to the regional licensing office within 24 hours any incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. Resident #1?s ?Progress Notes? [nursing notes] documented: A. On 09-13-2020, ?? observed resident on floor with blood on his temple area?? B. On 10-03-2020, ?Resident is very confused, and had a fall trying to get up out of bed? sustained a small skin tear on his left arm?? C. The regional licensing office did not receive incident reports from the facility regarding the aforementioned incidents. 2. Staff #1 and staff #2 acknowledged the aforementioned incidents involving resident #1 were not reported to regional licensing office.
Plan of Correction:	What Has Been Done to Correct? Any incident that has negatively affected the life, health, safety and welfare of any resident will be reported to the regional licensing office within 24 hours. Resident #1 passed away from unrelated causes on 1/14/2021. How Will Recurrence Be Prevented? The ED will communicate with RCD each day in our Stand-Up morning meeting regarding any incident that meets requirements to report to the regional licensing office. The ED or RCD will assure that the report will be made within 24 hours of any incident that meets the requirements for reporting. Person Responsible: Resident Care Director/Assistant Resident Care Director/ Executive Director
Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on record review and interview, the facility failed to implement their written plan for medication management to ensure each resident's prescription medications ordered are refilled in a timely manner to avoid missed dosages. Evidence: 1. Resident #2?s current signed physician?s orders dated 12-30-2020 (original physician?s order dated 10-06-2020) documented ?Atorvastatin Calcium Oral Tablet 20mg- 1 tablet by mouth every day. Dx: Hyperlipidemia.? 2. Resident #2?s November 2020 Medication Administration Record (MAR) documented staff did not administer Atorvastatin 20mg on 10-07-2020 through 10-15-2020. The documented reasons for the Atorvastatin 20mg not administered was ?pending delivery and awaiting on pharmacy arrival.? 3. Staff #2 provided a copy of the facility?s medication management policy labeled ?Handling, Ordering, and Refilling Medications (12/14/2020).? The policy documented ?If the House pharmacy delivers medications to the Community as part of their service agreement, all routine medications should be ordered prior to blister card running out?? 4. When asked if facility staff notified resident #2?s physician that the resident did not receive Atorvastatin 20mg on 10-07-2020 through 10-15-2020, staff #2 stated ?We do not have documentation that physician was notified that atorvastatin 20 mg was not given.? 5. Staff #1 and staff #2 acknowledged the facility did not implement their aforementioned policy for medication management to ensure resident #2?s Atorvastatin 20mg tablet was refilled in a timely manner to avoid missed dosages.
Plan of Correction:	What Has Been Done to Correct? Effective 12/31/2020, Resident #2?s medication is being refilled in a timely manner to avoid missed dosages of medication. Resident?s medication is being administered according to doctor?s orders. A record review was conducted on 1/5/2021 to ensure that there would be no additional missed medications for Resident #2 or any resident due to ordering of medications and/or refilling of medications. How Will Recurrence Be Prevented? Effective immediately, will follow our medication management policy on ?handling, ordering and refilling medications.? On 2/3/2021, direct care staff who administer medications were re-trained regarding the facility policy for medication management and were provided copies of the policy as well. The resident?s physician will be notified about any missed medications per our policy. Medications will be refilled in a timely manner to avoid missed dosages. Person Responsible: Resident Care Director/Assistant Resident Care Director
Standard #:	22VAC40-73-650-A
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure no medication or treatment is started by the facility without a valid order from a physician or other prescriber. Evidence: 1. Resident #3?s ?Progress Notes? [nursing notes] documented: A. On 11-01-2020, ?Resident was showered and lotioned down, cream and powder was applied to scrotum area.? B. On 11-02-2020, ?? home health nurse was in this morning to assess [residents? scrotum]? [Resident] had lots of cream on scrotum and between thighs. Scrotum red?? 2. Staff #2 stated, ?unsure of the name of the cream? applied to resident #3?s scrotum. Staff #2 stated ?the resident?s RP [responsible party] provided the cream? to the facility. Staff #2 could not provide documentation of a signed physician?s or prescriber?s order for resident #3?s cream. 3. Staff #2 acknowledged the facility did not have signed physicians? or prescribers? order prior to administering the cream to resident #3.
Plan of Correction:	What Has Been Done to Correct? Effective since date of inspection, no medication or treatment will be administered without a valid order from a physician or other prescriber, including over the counter creams or ointments. Resident #3 was discharged from community before this inspection so there is no change to resident?s orders regarding the cream that was administered. On 1/5/2021, all other resident?s rooms have been checked for any medications that are without a physician?s order. On 2/3/2021, direct care staff who administer medications were re-trained on ensuring that no medication or treatment be started by the facility without a valid order from a physician or other prescriber. How Will Recurrence Be Prevented? We will follow our medication management policy on the administration of medications and conduct a medication review audit weekly to make sure no medications are being administered without a physician?s order. Residents and their POAs were reminded via a letter sent out on 2/8/2021 that all medications must have a physician?s order, including over the counter medications like ointments. Person Responsible: Resident Care Director/Assistant Resident Care Director
Standard #:	22VAC40-73-650-B
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure physician orders, both written and oral, for administration of all prescription and over-the-counter medications, identified the diagnosis or specific indications for administering each drug. Evidence: 1. Resident #1 and resident #3?s signed physician?s orders did not include a diagnosis or specific indications for administering each of the following medications: A. Resident #1?s order dated 09-01-2020 for Acetaminophen 500 mg, Antacid 75 mg, and Fluzone 180 mcg/0.5 mL; order dated 11-03-2020 for Augmentin 500-125mg; and order dated 12-02-2020 for Escitalopram 10mg and Tylenol #3. B. Resident #3?s order dated 09-29-2020 for Donepezil 10mg and Trazadone 50mg; and order dated 09-10-2020 for Magnesium Oxide 400mg. 2. Staff #1 and staff #2 acknowledged resident #1 and resident #3?s physician?s orders did not include the diagnosis or specific indications for administering the aforementioned medications.
Plan of Correction:	What Has Been Done to Correct? Resident #1 and #3?s signed physician?s orders were corrected to include a diagnosis and specific indications for administering each medication. Each current resident?s record was audited to assure that proper diagnosis and specific indications for administering each medication was complete. How Will Recurrence Be Prevented? An audit of all resident records will be completed to assure that all physician?s orders include specific diagnoses and instructions for administering the medications. Person Responsible: Resident Care Director/Assistant Resident Care Director
Standard #:	22VAC40-73-650-F
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure whenever a resident is admitted to a hospital for treatment of any condition, the facility should obtain new orders for all medications prior to or at the time of the resident's return to the facility, and ensure the resident?s primary physician is made aware of all medication orders and has documented any contact with the physician regarding the new orders. Evidence: 1. Resident #1?s hospital ?Discharge Instructions and Information-After Visit Summary? dated 11-17-2020 documented the resident was admitted to the hospital on 11-14-2020 and discharged back to the facility on 11-17-2020. The After Visit Summary documented: A. Start Cephalexin 500mg 1 capsule by mouth 2 times a day for 7 days, start 11/17 evening; B. Change Lorazepam 0.5 mg tablet, take 1 tablet by mouth every 8 hours as needed (anxiety); C. Stop taking Aleve 220mg capsule. 2. Staff #2 could not provide documentation of contact made to resident #1?s primary physician regarding the new orders prior to or at the time of the resident?s return to the facility. 3. Staff #1 and staff #2 acknowledged the facility did not obtain new orders for the Cephalexin 500mg or Lorazepam 0.5mg and did not notify resident #1?s primary physician of the new aforementioned medication orders prior to or at the time of the resident?s return to the facility.
Plan of Correction:	What Has Been Done to Correct? Effective immediately, the resident?s primary physician will be made aware of all new orders upon return from any hospital stay. Resident #1?s orders were reviewed by primary physician and are accurate. All other resident?s orders have been reviewed for accuracy in an order audit conducted by the facility on 1/10/2021. How Will Recurrence Be Prevented? Upon any resident?s return from the hospital, the Resident Care Director will review all returning orders and will assure that the primary physician is made aware. Person Responsible: Resident Care Director
Standard #:	22VAC40-73-660-A-1
Complaint related:	Yes
Description:	Based on observation and interview, the facility failed to ensure the medicine cabinet or compartment used for storage of medications is locked. Evidence: 1. During a virtual tour of the facility with staff #2, 2 boxes of inhalers (identified by staff #2 as Flovent Inh 110/mcg); 3 bottles of eye drops (identified by staff #2 as Genteal Tears, Artificial Tears, and Restasis); and 1 bottle of Miralax were observed in an unlocked wall cabinet located in the medication room of the Assisted Living (AL) area. The wall cabinet did not contain a locking device and was unattended by staff, and the door leading into the medication room was open. 2. Staff #2 stated the contents in ?the inhalers, eye drops, and Miralax are full.? 3. Staff #1 & staff #2 acknowledged the aforementioned medications stored in the AL medication room wall cabinet were not locked and were left unattended. Staff #1 stated ?a lock will be added to the cabinet.?
Plan of Correction:	What Has Been Done to Correct? Immediately following the virtual tour of the area mentioned, the Resident Care Director had the Maintenance Director install locks on the cabinet. The locks will remain in place permanently. How Will Recurrence Be Prevented? A randomly scheduled audit ensuring that these cabinets are locked will be completed by the Assistant Resident Care and/or Resident Care Director. On 2/3/2021, direct care staff members were re-trained that all medications must be in a locked cabinet. Person Responsible: Assistant Resident Care Director/Resident Care Director
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure medications are administered in accordance with the physician's instructions. Evidence: 1. Resident #3?s current signed physician?s orders dated 10-09-2020 documented ?New orders: Add 10mg Donepezil in mid-day, keep QHS [at bedtime] dose. Total 20mg 1x day.? 2. Resident #3?s October 2020 Medication Administration Record (MAR) documented: A. Staff administered Donepezil 10mg at 8:00 AM on 10-12-2020 through 10-16-2020, and 10-18-2020 through 10-23-2020; and at 3:00 PM on 10-10-2020 through 10-26-2020. B. The resident did not receive Donepezil 10mg at bedtime per the physician?s instructions. 3. Staff #1 and staff #2 acknowledged resident #3?s Donepezil 10mg was not administered in accordance with the physician?s instructions.
Plan of Correction:	What Has Been Done to Correct? Effective immediately, the facility will ensure that medications are administered in accordance with the physician?s instructions. Resident #3 was discharged at the time of inspection. An audit of all resident?s medications and physician?s instructions was completed on 1/3/2021 for accuracy regarding administration of medications per physician?s orders. How Will Recurrence Be Prevented? Weekly audits will be conducted by Resident Care Director to assure that any medication administration and instruction changes will be noted and corrected. On 2/3/2021, direct care staff members were re-trained regarding ensuring medications are administered in accordance with physician?s instructions. Person Responsible: Resident Care Director
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure the Medication Administration Record (MAR) included the initials of direct care staff administering the medication. Evidence: 1. Resident #3?s October 2020 MAR did not include the initials of direct care staff administering DOK 100mg and Senna 8.6mg on 11-11-2020 at 8:00 AM. 2. Resident #4?s November 2020 MAR did not include the initials of direct care staff administering Calcium Citrate 315mg-200 on 11-07-2020 and 11-08-2020 at 8:00 AM and 1:00 PM, 11-22-2020 at 1:00 PM, and 11-23-2020 and 11-24-2020 at 5:00 PM; Quetiapine 25mg 11-07-2020 and 11-08-2020 at 8:00 AM; and Quetiapine 100mg 11-23-2020 and 11-24-2020 at 8:00 PM. 3. Staff #1 and staff #2 acknowledged the aforementioned dates did not include the initials of the direct care staff administering the medications.
Plan of Correction:	What Has Been Done to Correct? Direct care staff who administer medications were re-trained on the importance of the proper procedure regarding the administration of medication and initialing in the MAR. How Will Recurrence Be Prevented? At change of all shifts, the current direct care staff member administering medications will review the MAR to his/her signature on all medications administered before change of shift. If there is a missed signature or a missed medication, proper protocol will be followed based on the facilities written plan for medication management. The Resident Care Director will assure this is completed daily. Person Responsible: Resident Care Director/Assistant Resident Care Director