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: May 21, 2021 , May 24, 2021 and May 25, 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 22VAC40-90 The Criminal History Record Report

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 renewal inspection was initiated on 05-21-2021 and concluded on 05-25-2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 59. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, criminal background checks and sworn disclosures of newly hired staff, staff schedules, fire drills, fire and health inspection reports, dietary oversight, and healthcare oversight. Information gathered during the inspection determined non-compliance's with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the resident?s identified needs. Evidence: 1. Resident #1?s ?Resident Physical Examination Report? dated 07-20-2020 documented no added salt diet; however, the current ISP dated 07-31-2021 did not include the need for the aforementioned diet. The resident?s current Uniform Assessment Instrument (UAI) dated 07-31-2021 documented the need for mechanical and physical assistance with transferring and dressing; however, the ISP did not include documentation of the type of mechanical device needed for transferring and dressing. 2. Resident #2?s current UAI dated 06-02-2020 documented the need for mechanical and physical assistance with transferring; however, the current ISP dated 06-02-2021 did not include the type of mechanical device needed for transferring. 3. Resident #4?s ?Resident Physical Examination Report? dated 01-12-2021 documented allergies to iodine, shellfish, and tetanus vaccine; however, the current ISP dated 02-10-2021 did not include a description of the aforementioned allergies. 4. Staff #1 acknowledged the aforementioned ISP?s did not include a description of the residents identified needs.
Plan of Correction:	What Has Been Done to Correct? Effective 5/25/21, Resident #1?s ISP now includes the no salt added diet and the need for mechanical and physical assistance with transferring and dressing. Effective 5/25/21, Resident #2?s ISP now reflects the need for mechanical and physical assistance and effective 5/25/21, Resident #4?s ISP includes a list of allergies including iodine, shellfish and tetanus vaccine. How Will Recurrence Be Prevented? Effective 6/14/21, Resident Care Director and Assistant Resident Care Director will assure during completion of every ISP that dietary orders and mechanical and physical assistance needs are reflected accurately on the ISP by addressing these dietary orders on the ISP. Additionally, they will assure that all resident?s allergies are included on the ISP. As new orders are received, the Resident Care Director or Assistant Resident Care Director will update the ISP as needed. The Resident Care Director and/or Assistant Resident Care director will complete a monthly audit on all ISPs to assure that all areas on the UAI are properly addressed on the ISP. Person Responsible: Resident Care Director/Assistant Resident Care Director
Standard #:	22VAC40-73-650-A
Description:	Based on record review and interview, the facility failed to ensure no medications are discontinued by the facility without a valid order from the physician or other prescriber. Evidence: 1. Resident #4?s current signed physician?s orders dated 04-13-2021 documented: A: Alive B-Complex Gummies 4mg- Chew 1 gummy by mouth every day; B. Multivitamin Adult Gummies- Give 1 gummy by mouth every day; and C. Vitajoy gummies 2.5mg- Chew 1 gummy by mouth every day. 2. Resident #4?s May 2021 Medication Administration Record did not include the aforementioned medications nor documentation that the medications were administered. 3. Staff #1 did not provide documentation that staff administered Alive-B Complex Gummies, Multivitamin Adult Gummies, and Vitajoy Gummies to resident #4 from 05-01-2021 through 05-19-2021. 4. Staff #1 and staff #2 acknowledged the facility discontinued the aforementioned medications without a valid order from a physician or other prescriber.
Plan of Correction:	What Has Been Done to Correct? Effective on 5/25/21, Resident #4?s signed physician?s orders are being followed by all staff who administer medications including administering Alive B-Complex Gummies by mouth daily, Vitajoy Gummies and Multivitamin Adult Gummies per current physician?s order. How Will Recurrence Be Prevented? On 6/14/21, 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. All acknowledged that all physician?s orders will be compared to the current order MARS for verification of accuracy and that they will address any discrepancies. Per policy, physician?s order summaries, recaps are obtained from prescribers every six months to ensure current orders on hand for all medications. Person Responsible: Resident Care Director/Assistant Resident Care Director
Standard #:	22VAC40-73-650-B
Description:	Based on record review and interview, the facility failed to ensure prescriber?s 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 #4?s current signed prescriber?s orders dated 04-13-2021 did not include a diagnosis or specific indications for administering Acetaminophen 325mg, Alive B-Complex 4mg, Vitajoy gummies 2.5mg, Rivastigmine 4.6mg/24hr patch, and Multivitamin. 2. Staff #1 acknowledged the aforementioned prescriber?s orders did not include the diagnosis or specific indications for administering the medications.
Plan of Correction:	What Has Been Done to Correct? Effective 5/25/21, Resident #4?s current signed prescriber?s orders now include a diagnosis and specific indications for administering Acetaminophen 325mg, Alive B-Complex 4mg VitaJoy Gummies, 2/5mg Rivastigmine, 4.6mg/24hr. patch and Multivitamin. How Will Recurrence Be Prevented? Effective 5/26/2021, the Resident Care Director or Assistant Care Director will assure that the proper diagnosis is reflected on all resident?s orders via a weekly audit of prescriber?s orders, including the administration, identified diagnosis and specific instructions for administering each drug. Additionally, all staff who administer medications were retrained on 5/26/2021 on the community medication policy and procedure for ensuring prescriber?s orders, both written and oral, are correct. Person Responsible: Resident Care Director/Assistant Resident Care Director
Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview, the facility failed to administer medications in accordance with the physician?s instructions. Evidence: 1. Resident #3?s current signed physician?s orders dated 03-30-2021 documented Glipizide 2.5mg- take one tablet by mouth every morning for Diabetes; however, the April 2021 and May 2021 Medication Administration Records documented staff administered 1 tablet of Glipizide 5mg from 04-01-2021 through 05-19-2021. 2. Staff #1 and staff #2 did not provide an additional physician?s order documenting an increase of the Glipizide after the order dated 03-30-2021. 3. Staff #1 and staff #2 acknowledged resident #3?s Glipizide 2.5mg was not administered in accordance with the physician?s instructions.
Plan of Correction:	What Has Been Done to Correct? Effective on 5/25/21, Resident #3?s signed physician?s orders are being followed as ordered, including Glipizide at a dose of 2.5 mg. How Will Recurrence Be Prevented? Weekly audits will be conducted by Resident Care Director or Assistant Resident Care Director after the physician?s weekly visit to the community or after a resident?s physician?s visit to assure that any medication administration and instruction changes will be noted and corrected. On 5/26/21, current Registered Medication Aides or LPNs were re-trained regarding ensuring medications are administered in accordance with physician?s instructions. This training included a review of the ?three check method? and Six Rights of medication administration to ensure accuracy. Person Responsible: Resident Care Director/Assistant Resident Care Director
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review and interview, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. Staff #1 provided a list of newly hired staff and dates of hire; to include staff #6 (date of hire on 02-10-2021), staff #7 (date of hire on 04-08-2021), and staff #8 (date of hire on 11-10-2020). 2. Staff #6?s criminal history record report dated 02-11-2021, staff #7?s report dated 04-14-2021, and staff #8?s report dated 04-21-2021 were not obtained on or prior to the 30th day of employment. 3. Staff #1 could not provide additional criminal history record reports obtained for the aforementioned staff, and acknowledged the facility did not obtain a criminal history record report within the required timeframe.
Plan of Correction:	What Has Been Done to Correct? Prior to the DSS renewal inspection, once discovered, the criminal background checks, with correct name spelling of staff #6, #7, and #8 were obtained. In addition, as of 5/25/21, no new employee will be hired without a complete, accurate background check. How Will Recurrence Be Prevented? Effective 5/21/21, the Business Office Manager will not allow anyone without an accurate and timely background check to be hired. Prior to the new employee hire date and as part of our staff hiring process, the Executive Director will assure that this policy has been followed. The Executive Director sampled an additional 10 employee records to ensure compliance with background check requirements. All 10 records were in compliance. Person Responsible: Business Office Manager/Executive Director
Standard #:	22VAC40-90-50-B
Description:	Based on record review and interview, the operator of the facility failed to ensure that each criminal history record report was verified by matching the name to establish that all information pertaining to the individual cleared through the Central Criminal Records Exchange is exactly the same as another form of identification such as a driver's license. The operator of the facility failed to request a new criminal history record when the information did not match. Evidence: 1. Staff #1 provided a list of newly hired staff with dates of hire; to include staff #9 (date of hire on 08-12-2020). 2. Staff #1 provided copies of staff #9?s driver?s licenses. Staff #9?s first name shown on the driver?s licenses did not match the first name documented on the criminal history record report dated 07-31-2020. 3. Staff #1 did not provide documentation of new criminal history record documenting the correct name for staff #9, and acknowledged the incorrect spelling of staff #9?s name documented on the criminal history record report.
Plan of Correction:	What Has Been Done to Correct? Staff member #9, whose record was reviewed, was terminated on April 1, 2021, prior to the DSS renewal inspection. How Will Recurrence Be Prevented? Effective immediately, the Business Office Manager will thoroughly review and verify that the name on the criminal background check matches another form of identification prior to an employee being hired. If an error is discovered, the background check will be completed again with accurate information. Person Responsible: Business Office Manager