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: April 14, 2021 , April 15, 2021 , April 19, 2021 , April 20, 2021 and April 21, 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

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 04-14-2021 and concluded on 04-21-2021. A complaint was received by the department regarding allegations in the areas of Incident Reports; Staffing and Supervision; Personal Care Services and General Supervision of Care; and Administration of Medications and Related Provisions. 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 #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to 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: 1. Resident #1?s staff ?Progress Notes? dated 03-31-2021 documented, ?? Resident tried to get up without assistance and fell and hit [resident?s] head 911 was called and [resident] was sent back to [hospital] for evaluation?? The regional licensing office did not receive incident report from the facility within 24 hours regarding this incident. 2. Staff #1 and staff #2 acknowledged the aforementioned incident was not reported to the regional licensing office within 24 hours.
Plan of Correction:	What Has Been Done to Correct? On 4/29, the RMA and RCA staff were retrained about the protocol for letting the ED, RCD and ARCD know of any incidents that negatively affect the life, health or safety of a resident. In addition, the ED, ARCD, RCD are all now completing any initial incident reports within 24 hours. How Will Recurrence Be Prevented? During the stand up meeting each day, all incidents that negatively affect the life, health or safety of a resident will be discussed. Either the ED, RCD or ARCD will complete the report to DSS within the 24-hour time frame per the DSS standard. The designated Manager on Duty on Saturday and Sunday will report any incidents that negatively affect the life, health or safety of a resident to both the RCD and ED immediately. Person Responsible: RCD and ED
Standard #:	22VAC40-73-325-C
Complaint related:	No
Description:	Based on record review and interview, the facility failed to document an analysis of the circumstances of the fall for residents who meet the criteria for assisted living care. Evidence: 1. Resident #1's Uniform Assessment Instrument (UAI) dated 02-11-2021, resident #2?s UAI dated 02-23-2021, and resident #4?s UAI dated 04-06-2021 documented the residents? meet criteria for assisted living level of care. 2. Staff ?Progress Notes? indicated the following falls: A. 03-15-2021, resident #1 fell on the floor; and on 03-31-2021, resident fell and hit; B. 03-13-2021, resident #2 on the floor. Resident was lying on right side? bleeding from head? laceration to the back of [resident?s] head? CT showed a mild compression fracture to 2nd thoracic vertebrae?; and C. 02-05-2021, resident #4 was observed lying on the floor; and on 03-18-2021, was in laying in the entrance way of the bathroom. 3. Staff #2 stated ?We do not have any documentation of analysis of the fall for resident #2, resident #4, resident #1?.? 4. Staff #1 and staff #2 acknowledged the facility did not document an analysis of the circumstances of the falls for residents? #1, #2, or #4.
Plan of Correction:	What Has Been Done to Correct? Effective 5/10/21, a fall analysis report will be completed on any resident post fall to ensure regulatory compliance with 22 VAC40-73-(5)-325-C. A fall analysis report has been completed on resident?s #1, #2 and #4 on 5/10/21 and interventions have been implemented as indicated. How Will Recurrence Be Prevented? Effective on 5/10/21, Fall Analysis report sheets will be generated by RCD or ARCD as needed and interventions will be put into place for each resident post fall. Person Responsible: RCD, ARCD
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, new orders are obtained for all medications prior to or at the time of return to the facility. The residents primary physician was not made aware of all medication orders nor was there documentation of any contact with the physician regarding the new orders. Evidence: 1. Resident #1?s hospital ?Discharge Instructions and Information-After Visit Summary? dated 03-31-2021 instructed to change Vitamin D3 from 50 mcg to 75 mcg. A. March 2021 and April 2021 Medication Administration Record (MAR) documented staff administered Vitamin D3 50 mcg from 03-31-2021 through 04-20-2021. B. Staff #2 stated, ?The discharge summary that states change the way Vit D is taken was not initiated.? 2. Resident #4?s hospital ?Discharge Instructions and Information-After Visit Summary? dated 03-18-2021 documented ?start 1 baby aspirin daily.? A. March 2021 MAR documented Aspirin 81mg was started on 03-31-2021. B. Staff #2 could not provide documentation verifying staff administered Aspirin 81mg on 03-19-2021 through 03-30-2021. C. Staff #2 stated resident #4?s ?discharge summary did not get faxed until a few days later and once the ASA 81mg [Aspirin] was entered in Yardi that is when the ASA 81mg was approved and started.? 3. Staff #2 could not provide documentation of new orders obtained for the aforementioned medications, nor documentation of contact made to resident #1 and resident #4?s primary physicians regarding the new orders prior to or at the time of the resident?s return to the facility. 4. Staff #1 and staff #2 acknowledged the facility did not obtain nor notify resident #1 and resident #4?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? Resident #1?s medication administration record reflects the new order to change Vitamin D3 from 50 mcg to 75 mcg per primary care physician?s order. Resident #4?s medication administration record reflects the new order to start 1 baby aspirin daily per primary care physican?s order. The new orders for medications were obtained for resident #1 and resident #4. How Will Recurrence Be Prevented? Effective immediately, new orders will be obtained for all medications prior to or at the time of discharge to the facility. The RCD or ARCD will review all new orders prior to a resident?s return to the community from a hospital stay. Orders will then be changed or updated on the medication administration record as appropriate with approval of primary care physician. Person Responsible: RCD, ARCD