VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Cedar Manor
1324 Cedar Road
Chesapeake, VA 23222
(757) 548-4192

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Feb. 3, 2021 , Feb. 9, 2021 and Feb. 10, 2021

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 monitoring inspection was initiated on 02-03-2021 and concluded on 02-10-2021. The Interim Administrator was contacted by telephone to initiate the inspection. The Interim Administrator reported that the current census was 46. 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, 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 #:	22VAC40-73-440-B
Description:	Based on record review and interview, the facility failed to ensure the Uniform Assessment Instrument (UAI) for private pay individuals was completed by a staff person who has successfully completed state-approved training on the UAI. Evidence: 1. Resident #1?s UAI dated 12-01-2020 was completed by staff #4. 2. Staff #1 could not provide documentation verifying staff #4 completed the UAI state-approved training, and stated ?We do not have a record of the UAI/ISP certification for staff #4.? 3. Staff #1 and staff #2 acknowledged resident #1?s UAI was not completed by a staff person who has successfully completed the UAI state-approved training.
Plan of Correction:	What Has Been Done to Correct? Documentation of successful completion of state approved UAI training have been obtained and filed for the RCD and ED. How Will Recurrence Be Prevented?UAI assessments will be completed by qualified staff who have successfully completed training via one of the following methods: ? Through a certificate for the online course, ADS 1102: Private Pay Uniform Assessment Instrument located on the Department of Social Services (DSS) Knowledge Center. The certificate of successful completion of the course must be placed in the assessor?s personnel file or; ? Through a certificate of the classroom training ADS 5011: Uniform Assessment Instrument (UAI) offered by DSS. Person Responsible: The ED will be responsible for ensuring successful completion of state-approved training for any staff person completing UAIs.
Standard #:	22VAC40-73-450-B
Description:	Based on record review and interview, the facility failed to ensure the designee successfully completed the department approved Individualized Service Plan (ISP) training. Evidence: 1. Resident #1?s ISP dated 12-01-2020, resident #2?s ISP dated 01-20-2021, and resident #3?s ISP dated 01-21-2021 was developed by staff #4. 2. Staff #1 nor Staff #4 could not provide documentation verifying completion of the department approved ISP training. 3. Staff #1 and staff #2 acknowledged the ISP?s were developed by a staff #4 who had not successfully completed the approved training.
Plan of Correction:	What Has Been Done to Correct? Documentation verifying successful completion of VDSS approved ISP training has been obtained and filed for the RCD and ED. How Will Recurrence Be Prevented? Comprehensive ISPs will be developed by qualified staff who have successfully completed the department-approved individualized service plan (ISP) training, provided by a licensed health care professional practicing within the scope of his profession to meet the resident's service needs. Verification of state-approved private pay UAI training will also be obtained. Person Responsible: The ED will be responsible for ensuring successful completion of state-approved training for any staff person completing ISPs.
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 identified needs. Evidence: 1. Resident #2?s ?Report of Resident Physical Examination? dated 10-09-2020 documented allergies to Codeine, Shellfish containing products, and Cyclobenazapin. Resident #2?s current Uniform Assessment Instrument (UAI) dated 11-19-2020 documented the need for mechanical assistance with walking and stairclimbing; however, current ISP dated 01-20-2021 did not document these needs. 2. Resident #3?s current UAI dated 01-20-2021 documented bowel and bladder incontinence weekly or more; however, the current ISP dated 01-21-2021 did not document these needs 3. Staff #1 and staff #2 acknowledged resident #2 and resident #3?s aforementioned needs were not identified on the ISP?s.
Plan of Correction:	What Has Been Done to Correct? Planned (ISP) meetings: Executive Director (ED) and Resident Care Director are scheduling Individualized Service with seven residents and their legal representatives each week beginning March 15, 2021. All necessary assessments will be completed prior to developing each ISP to ensure all identified needs are accurately notated on the plan of care. How Will Recurrence Be Prevented? Resident #2 UAI & ISP has been corrected. Resident # 3 has expired. ISPs will be reviewed and updated at least once every 6 months and as needed for a significant change of a resident's condition. The review and update shall be performed by a qualified staff person, in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons. All Care and services specified in the individualized service plan will be provided to each resident, except when: 1. A deviation from the plan when mutually agreed upon between the facility and the resident or the resident's legal representative at the time the care or services are scheduled or when there is an emergency that prevents the care or services from being provided. 2. Any deviation from the plan shall: a. Be documented in writing or electronically; b. Include a description of the circumstances warranting deviation and the date such deviation will occur; c. Certify that notice of such deviation was provided to the resident or the resident's legal representative; d. Be included in the resident's file; and e. Be signed by an authorized representative of the assisted living facility and the resident or the resident's legal representative if the deviation is made due to a significant change in the resident's condition. Person Responsible: The RCD will be responsible for ensuring ISPs include a description of identified needs in conjunction with clinical assessments, physician?s orders, and resident choice.
Standard #:	22VAC40-73-680-I
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. January 2021 MAR?s did not include the initials of direct care staff who administered the following medications: A. Resident #1?s Montelukast 10mg, Rosuvastatin 10mg, and Trazadone 50mg on 01-10-2021 at 8:00 PM; B. Resident #2?s Potassium CL 20meq, Refresh Liquigel, and Preservision Cap Areds 2 on 01-10-2021 at 5:00 PM; Atorvastatin 40mg on 01-10-2021 at 8:00 PM; Eliquis 2.5mg, Melatonin 3mg, and Mucinex 300mg on 01-10-2021 at 8:30 PM; and C. Resident #3?s Carbamazepin 200mg on 01-04-2021 at 5:30 PM; and Clonazepam 0.5mg and Nystatin Cre 100000 at 10:00 PM. 2. Staff #1 and staff #2 acknowledged the aforementioned MAR did not include the staff initials on the aforementioned dates.
Plan of Correction:	What Has Been Done to Correct? Daily audits of medication administration records are conducted to verify proper documentation of medication administration on the electronic medication administration record (EMAR). Medications that are not administered per physician?s orders have a correlating reason (refusal, LOA, etc.) documented in the EMAR. Paper Medication Administration Records (MAR) have been printed to ensure compliance with organizational policies during system outages. How Will Recurrence Be Prevented? Resident Care Director (RCD) called for a meeting with staff persons who administer medication. RCD reviewed organization?s Medication Management and Medication Administration Records policies. An in-service has been scheduled with Southern Pharmacy, concentrated on staff persons responsible for administering medications, to review proper user operation of the EMAR system and best practices for system outages. Community will continue to conduct daily audits of missed documentation in EMAR. Individual employee in-services will be implemented for team members who neglect organizational guidelines relating to medication management and medication administration record policies. Paper MARs will be printed monthly and as needed to ensure proper documentation of medication administration in the event of system outages. Person Responsible: The Resident Care Director and the Assistant Resident Care Director will be responsible for ensuring proper documentation of administered medications in the EMAR system. The Assistant Resident Care Director will be responsible for ensuring paper MARs are printed for each resident monthly and as needed. The Executive Director will be responsible for conducting unscheduled audits to ensure the aforementioned practices are executed continuously.