VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Williamsburg
236 Commons Way
Williamsburg, VA 23185
(757) 564-4433

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Nov. 9, 2020 , Nov. 11, 2020 , Dec. 14, 2020 and Jan. 12, 2021

Complaint Related: Yes

Areas Reviewed:

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 11-10-20 and concluded on 1-12-21. A complaint was received by the department regarding an allegation in the areas of resident care and related services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator 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 #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan included all of the required information for five of five residents. Evidence: 1-Resident #1?s individualized service plan (ISP) dated 8-22-20 did not include who would provide services and when and where services will be provided for assessed activities of daily living (ADL), instrumental activities of daily living (IADL) and other assessed needs documented on the ISP. a-Resident #1?s Physician Orders dated 6-19-20 and Face Sheet Profile documented the following allergies: Sulfa Antibiotics, Beta Adrenergic Blockers, Codeine, Furosemide, Hydromorphone, Demerol HCL, Morphine, Prednisone, Vancomycin, Percocet, Cardizem, Plavix, Apixaban and Xarelto. The allergies were not documented on the ISP. b-Resident #1?s uniformed assessment instrument (UAI) dated 8-22-20 documented medication administration by lay person and professional nursing staff. This information not documented on the ISP. 2-Resident #2?s ISP dated 8-20-20 did not include who would provide services, when and where services will be provided for assessed ADLs, IADLs and other assessed needs documented on the ISP. a-Resident #2?s Physician Order Review dated 9-2-20 and 10-1-20 and Face Sheet Profile documented the following allergies: Cortisone, Dicyclomine, Vicodin, Ciprofloxacin and Zithromax. The allergies not documented on the ISP. b-Resident #2?s uniformed assessment instrument (UAI) dated 8-20-20 documented medication administration by lay-person and professional nursing staff. This information not documented on the ISP. 3-Resident #3?s ISP dated 11-10-20 did not include who would provide services, when and where services will be provided for assessed ADLs, IADLs and other assessed needs documented on the ISP. a- Resident #3?s progress notes dated 9-25-20 at 10:02 p.m. and 10-1-20 at 4:58 a.m. documented oxygen therapy. On 1-12-21, staff #1 acknowledged resident?s use of oxygen. This information not documented on the ISP. b- Resident #3?s physical examination dated 8-18-20 documented resident allergic to Halcion. The allergy not documented on the ISP. c-Resident #3?s uniformed assessment instrument (UAI) dated 8-18-20 documented medication administration by lay person and professional nursing staff. This information not documented on the ISP. 4-Resident #4?s ISP dated 9-5-20 did not include who would provide services, when and where services will be provided for assessed ADLs, IADLs and other assessed needs documented on the ISP. a-Resident #4?s record included an electronically signed physician order dated 6-8-20 documented, ?home physical therapy/occupational therapy to evaluate and treat. Home health to evaluate and provide home health aide to assist with mobility when indicated?. Therapy services were not documented on the ISP. b-Resident #4?s admitting physical examination and Face Sheet Profile documented the following allergies: Bactrim, Cefadroxil, Sulfa, Tamsulosin, and Peanuts. The allergies not documented on the ISP. c-Resident #4?s uniformed assessment instrument (UAI) dated 8-5-20 documented medication administration by lay person and professional nursing staff. This information not documented on the ISP. 5-Resident #5?s ISP dated 8-20-20 did not include who would provide services, when and where services will be provided for bathing, IADLS and other assessed needs documented on the ISP. a-Resident #5?s Physician Order Review (POR) dated 9-1-20, POR dated 10-1-20, POR dated 11-1-20 and Resident Face Sheet Profile documented allergy to Donepezil and Latex. The allergies not documented on the ISP. b-Resident #5?s uniformed assessment instrument (UAI) dated 8-20-20 documented medication administration by lay person and professional nursing staff. This information not documented on the ISP. 6-On 1-12-21, staff #1 confirm ISPs missing information
Plan of Correction:	What Has Been Don to Correct? Residents 1,2,3,4 and 5 UAIs and ISPs have been updated to reflect needs, allergies and who will provide services. How Hill Recurrence Be Prevented? ED, RCD or designee to perform random monthly audits of UAI's and ISP's to ensure ongoing compliance. RCD and ARCD will update ISP semi-annually or upon change of resident condition. Person Responsible: ED, RCD or designee Due Date 3/31/21
Standard #:	22VAC40-73-450-D
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure, when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan. Evidence: .1-Resident #2?s progress notes on 9-28-20 at 2:03 pm documented ?resident was complaining of rib pain Hospice was called and they was in to follow up on pain and situation?. Resident?s individualized service plan (ISP) dated 8-20-20 did not document hospice services. On 1-12-21, Staff #1 acknowledged resident received hospice care services. 2-Resident #5?s progress note dated 10-29-20 at 2:20 p.m. documented, ??Hospice has been in to visit and new orders have been made, awaiting of meds morphine and fetnal patches will continue to monitor resident?. Progress note dated 10-26-20 at 10:26 p.m. documented, ??resident had fallen?swollen right hip, right foot swollen and bruises on back of both hands. Hospice was notified?.? Progress note dated 9-19-20 at 1:40 p.m. documented, ??morning episode of vomiting hospice is aware?? Hospice services not documented on resident?s ISP dated 8-20-20.
Plan of Correction:	What Has Been Done to Correct? Residents 1 and 4 ISP updated to reflect resident's current needs and services. How Will Recurrence Be Prevent? ISP's will be reviewed upon move in, change in condition and with semi-annual reviews Person Responsible: RCD, ARCD or designee Due Date: 3/31/21
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan was updated as needed as the condition of the resident change for two residents of five residents. Evidence: 1.Resident #4?s ISP dated 9-5-20 was not updated as the resident?s condition changed. Resident #4?s record included an electronically signed physician order dated 6-8-20 documented, ?home physical therapy/occupational therapy to evaluate and treat. Home health to evaluate and provide home health aide to assist with mobility when indicated?. Resident?s #4?s admission physical indicated resident not able to ambulate independently. Therapy services were not documented on the resident?s ISP. 2. Resident #1?s ISP dated 8-22-20 was not updated as the resident?s condition changed. Resident #1?s progress note dated 10-6-20 documented resident?s enrollment for skilled services from a homehealth agency. Review of document read, ??nursing (homehealth) will be in on Thursday, speech on wed, PT twice a week.? According to staff #1, resident received skilled services from a homehealth agency. This information was not documented on the resident?s ISP.
Plan of Correction:	What Has Been Done to Correct? Resident 1 and 4 ISP updated to reflect resident's current needs and services. How Will Recurrence Be Prevented? Cart audit will be performed randomly on 3 to 4 residents monthly. Ongoing coaching and training of Med Associates. Person Responsible: RCD, ARCD, or designee Due Date: 3/31/21
Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on record review and staff interview, the facility failed to follow the facility's written medication management plan so that resident's prescription medications and any over-the counter drugs and supplements for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: 1-Resident #1?s October 2020 medication administration record (MAR), staff documented Klor-Con, 8:00 a.m. dosage on 10-9-20, ?not on cart?. Resident?s November 2020 MAR documented Calcium and Klor-Con, 8:00 a.m. dosage on 11-1-20, ?medication not on hand?. 2-Resident #2?s September 2020 MAR documented Oxycodone with Acetaminophen 8 p.m. dosage on 9-1-20 documented, ?not on hand not given?. Resident?s Aspercreme Pad Lido 4% 8:00 a.m. dosage on 9-12-20 documented, ?has been ordered?. Resident?s Aspercreme patch is prescribed daily at 8 a.m. per residents September 2020 MAR and September 1, 2020 Physician Review Order. 3-Resident #3?s September 2020 MAR, documented Acetaminophen-Extra strength 8 a.m. dosage on 9-2-20, 9-3-20, 9-14-20 and 9-16-20 medication ?not available? and 9-12-20, ?drug not available?. Preservision Areds 8 a.m. dosage on 9-2-20, documented ?not available? and 9-4-20, ?awaiting for pharmacy to deliver?. Preservision Areds 8 p.m. dosage documented on 9-1-20, ?medication not on hand not given?; 9-2-20 through 9-4-20, ?not available?. Resident #3?s November 2020 MAR, Preservision Areds, 8 a.m. dosage documented on 11-1-20, ?medication not hand? and the 8 p.m. dosage on 11-7-20, ?not available?. 4-Resident #5?s October 2020 MAR documented Oxycodone with Acetaminophen (DNA-drug not available, ?not in cart? on 10-28-20 for the 8 am dosage and on 10-27-20, 8 p.m. dosage, ?awaiting pharmacy delivery?. October 2020 Mar and October Physician Review form documented medication prescribed twice a day (8 a.m. and 8 p.m.)
Plan of Correction:	What Has Been Done to Correct? Registered Med Associates in-serviced on medication management on appropriately ordering and refilling of medications. How Will Recurrence Be Prevented? Cart audit will be performed randomly on 3 to 4 residents monthly. On going coaching and training of Med Associates. Person Responsible: RCD, ARCD, or designee Due Date: 3/31/21
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record review and staff 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 registration medication aide curriculum approved by the Virginia Board of Nursing for two of five residents record reviewed. Evidence:. 1-Resident #1?s November 2020 medication administration record (MAR) documented Warfarin 2mg prescribed for Monday and Friday at 6:00 p.m (physician order 9-22-20) was initialed by staff on Tuesday 11-3-20; Wednesday 11-4-20; Saturday 11-7-20 and Sunday 11-8-20. 2-Resident #4?s November 2020 MAR, documented Warfarin 2.5mg (take 1/2 tab 1.25mg) on Tuesday and Saturday at 5 p.m (physician order 11-2-20) was initialed by staff on Wednesday 11-4-20, Sunday 11-8-20 and Monday 11-9-20. 4-On 1-12-21, Staff #1 acknowledged resident?s documentation of medications by staff were not accurately documented.
Plan of Correction:	What Has Been Done to Correct? Resident 1 and 4 orders corrected to reflect appropriate dose and day for administration. How Will Recurrence Be Prevented? Medication audits will be completed in conjunction with Physician order reviews and upon move in and with oversight recommendations by pharmacy. Person Responsible: RCD, ARCD, or designee Due Date: 3/31/21
Standard #:	22VAC40-73-680-I
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure the medication administration record (MAR) included all required information for five residents record reviewed. Evidence: 1.Residents' medication administration records (MARs) for September 2020, October 2020 and November 2020 did not include the diagnosis, condition, or specific indications for administering the following drug or supplement: a. Resident #1: Amlodipine, Bumetanide, Calcium, Calcium Carbonate, Docusate Sodium, Escitalopram Oxalate, Lipitor, Lisinopril, Mag Oxide, Omeprazole, Vitamin B-12 and Warfarin Sodium. b.Resident #2?s September 2020 MAR: Mirtazapine, Vitamin D3, Aspercreme Patch and Ensure. October 2020 MAR: Mirtazapine, Vitamin D3 and Aspercreme Patch. November 2020 MAR: Mirtazapine and Vitamin D3. c.Resident #3?s September 2020, October 2020 and November 2020 MAR: Acetaminophen. d.Resident #4?s November 2020 MAR: Amiodarone HCL, Furosemide, Glimepiride, Nystatin topical powder, Warfarin, and Mesalamine. e.Resident #5?s October 2020 and November 2020 MAR:Ondansetron. 680-I.9 1.Resident #1?s November 1 through 9, 2020 medication administration record (MAR) did not include initials/was blank 6 times each for the following medications scheduled at 8:00 a.m (a) Amlodipine Besylate, (b) Bumetanide, (c) Calcium 600, (d) Calcium Carbonate, (e) Colace, (f) Escitalopram Oxalate, (g) Klor-Con, (h) Lisinopril, (i) Mag Oxide, (j) Metoprolol Tartrate, (k) Vitamin B-12 and Vitamin D3. Omeprazole scheduled for 7:30 a.m. blank 6 times. 2.Resident #2?s November 1 through 9, 2020 medication administration record (MAR) did not include initials/was blank 6 times each for the following medications scheduled at 9:00 a.m. (a) Sienna Plus, (b) Sertraline, (c) Skin Prep treatment and (d) Vitamin D3. Quetiapine Fumarate scheduled at 1:00 p.m. blank 6 times. Skin Prep treatment scheduled at 2:00 p.m. blank 6 times. Mirtazapine scheduled at 8:00 p.m. blank 1 time and Bisacodyl scheduled at 8:00 a.m. on Monday and Thursday, blank 3 times. 3.Resident #3?s November 1 through 9, 2020 medication administration record (MAR) did not include initials/was blank 6 times each for the following medications scheduled at 8:00 a.m. (a) Eliquis, (b) Levothyroxine Sodium, (c)Metoprolol Tartrate, (d) Potassium Chloride Crystals and (e) PreserVision AREDs. Furosemide scheduled for 9:00 a.m. blank 6 times and PreserVision AREDs scheduled for 8:00 p.m. blank 2 times. 4.Resident #4??s November 1 through 9, 2020 medication administration record (MAR) did not include initials/was blank 6 times for each of the following medications scheduled at 8:00 a.m. (a) Aspirin, (b) Calcitrol, (c) Furosemide, (d) Glimepiride, (e) Polyethylene Glycol, (f) Probiotic Cap and (g) Vitamin B-12. Also, Accucheck schedule for 7:30 a.m. blank 6 times and 4:30 p.m. blank 1 time. Amiodarone HCL scheduled for 8:00 a.m. blank 6 times and 8:00 p.m. 7 times. Gabapentin scheduled for 9:00 a.m. and 1:00 p.m. blank 6 times and 5:00 p.m. blank 1 time. Mapap Arthritis scheduled for 8:00 a.m and 1:00 p.m. blank 6 times and 5:00 p.m. blank 1 time. Nystatin scheduled for 8:00 a.m. blank 6 times and 7:00 p.m. blank 7 times. Pantoprazole Sodium scheduled for 7:30 a.m. blank 6 times. 5.Resident #5?s November 1 through 9, 2020 medication administration record (MAR) did not include initials/was blank for the following medications: (a) Ondansetron scheduled for 7:00 a.m. blank 7 times, 11:00 a.m. blank 6 times and 4:00 p.m. blank 1 time. (b) Oxycodone with Acetaminophen scheduled for 8:00 a.m. blank 7 times. 6.On 1-12-21, Staff #1 acknowledged Mars were not documented by staff and was blank for September, October and November 2020.
Plan of Correction:	What Has Been Done to Correct? EMAR system error was identified. Error was preventing initials of a particular med tech form appearing on EMAR when medications were given. Residents 1,2,3,4 and 5 medications orders will reflect appropriate diagnosis. How Will Recurrence Be Prevented? Error was corrected and initials now appear on EMAR. Resident diagnosis will be reviewed upon move in, semi-annual reviews and with physician order reviews. Person Responsible: RCD, ARCD or designee Due Date: 3/24/21