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: March 22, 2021 , March 24, 2021 , March 29, 2021 , March 31, 2021 and April 1, 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 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 03-22-2021 and concluded on 04-01-2021. A complaint was received by the department regarding allegations in the areas of staffing and supervision, administration of medications and related provisions, resident Agreement, medication management plan, personal care services and general supervision of care, storage of medications, and provisions for signaling and call systems. 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 #:	22VAC40-73-50-A
Complaint related:	No
Description:	Based on record review and interview, the facility did not keep its disclosure statement current regarding the general number of direct care staff (DCS) on each shift. Evidence: 1. The facility?s disclosure statement documented 8 DCS will work during the 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts. 2. February 2021 and March 2021 facility staff working schedules and timesheets documented: A. 02-10-2021, 6 DCS worked during the 3:00 PM - 11:00 PM and 11:00 PM - 7:00 AM shifts; B. 02-14-2021, 02-23-2021, and 03-04-2021, 4 DCS worked during the 3:00 PM - 11:00 PM and 11:00 PM - 7:00 AM shifts. 3. Staff #1 confirmed the number of DCS who worked during the aforementioned dates and times and acknowledged the total number of DCS working did not reflect the number of DCS in the disclosure statement.
Plan of Correction:	Disclosure Statement is being revised to reflect current staffing numbers. Once revisions have been made, each resident/legal representative will be provided a copy of the revised Disclosure Statement to review and sign. The assisted living facility shall prepare and provide a statement to the prospective resident and his legal representative, if any, that discloses information about the facility. The statement shall be on a form developed by the department and will include current statement of the general number of direct care staff (DCS) on each shift. The Executive Director is responsible for ensuring residents/legal representative is provided a disclosure statement within standards of practice consistent with 22VAC40-73-(2)-50-A
Standard #:	22VAC40-73-390-A
Complaint related:	Yes
Description:	Based on record review and interview, the written agreement did not include documentation of the resident being informed of the policy regarding the administration of medications and dietary supplements. Evidence: 1. The licensee took ownership of the facility effective 11-18-2020. 2. Resident #1?s written agreement, signed and dated on 12-15-2020, and resident #4 and resident #5?s written agreement, signed and dated on 03-23-2021, did not include documentation that the residents were informed of the policy regarding the administration of medications and dietary supplements. 3. Staff #1 did not provide documentation that the aforementioned residents were informed of the facility?s policy regarding the administration of medications and dietary supplements. 4. Staff #1 acknowledged the aforementioned written agreements did not include documentation that the residents were informed of the policy regarding the administration of medications and dietary supplements.
Plan of Correction:	What Has Been Done to Correct? Executive Director has submitted Notice of Violation to Home Office for review and revision. Once revisions have been made, current residents/legal representatives will be provided an agreement addendum, complaint with regulatory standard, to review and sign. All residents admitted thereafter will sign a copy of the revised resident agreement. How Will Recurrence Be Prevented? Resident agreements will be reviewed by Licensee, as needed, to ensure compliance with regulatory standards. Person Responsible: Licensee is responsible for ensuring compliance with ensuring regulatory standard of resident agreement.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the residents identified needs. Evidence: 1. On 03-24-2021, during a virtual tour of the facility with staff #1, right side rails was observed on resident #1 and resident #2?s beds, and left side rail on resident #3?s bed. 2. Resident #1?s current ISP dated 12-01-2020, resident #2?s current ISP dated 01-21-2021, and resident #3?s current ISP dated 01-20-2021 did not document the needs for side rails. 3. Staff #1 acknowledged the side rails on residents #1, #2, and #3?s bed were not documented on the residents ISP?s.
Plan of Correction:	Residents with side rails will have ISP updated to include the need for siderails. Resident ISPs will reflect the needs and services provided to each resident and will be reviewed and signed by of an authorized representative of the facility and the resident or resident?s legal representative. Health Care Oversight will be conducted by a non-community associate to ensure ISPs are consistent with the needs of the resident. The Resident Care Director or designee is responsible for ensuring the resident?s ISP documents the needs of the resident and the services provided to the resident. Executive Director will conduct random audits of ISPs to ensure plan of care reflects residents needs.
Standard #:	22VAC40-73-460-B
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure prompt response by staff to resident needs. Evidence: 1. ?Resident Council Concerns Checklist? forms dated 02-11-2021 and 03-19-2021 documented, ?Residents stated call bells are not being answered when they call for help;? and ?Call bells are being ignored and residents are left to wait long periods of time? Showers are not to be given when they are supposed to. Residents waiting for shower and no one comes.? 2. During interviews, residents stated ?Staff takes a long time to respond to call bell, it varies [time], but have waited up to an hour, and sometimes there is no response;? call bells ?were a problem;? and ?not enough staff to provide care.? 3. Staff #1 provided a copy of the facility?s call bell log labeled ?Zone Activity Report? which documented the following response times: A. On 02-10-2021, 1 hour and 7 minutes for room 106 at approximately 8:08 AM; 28 minutes for room 205 at approximately 8:05 AM; and 28 minutes for room 205 at approximately 1:11 PM; B. On 02-14-2021, 31 minutes for room 106 at approximately 2:26 AM; 48 minutes for room 106 at approximately 12:03 PM; and C. On 03-24-2021, 37 minutes for room 106 at approximately 6:48 AM.; 28 minutes for room 205 at approximately 5:04 AM; and 29 minutes for room 205 at approximately 11:36 PM. 4. Staff #2 stated the facility?s goal is to ?answer the call bells within 7 minutes?, and acknowledged the residents? concerns regarding the delayed response times to the call bells.
Plan of Correction:	Call bell response times have consistently improved since March 2021 and have averaged 7 min or less for the past 30 days. Routine monitoring of call be response times has been implemented. Residents have been educated on communicating malfunctioning call bell system equipment to a member of management as soon as possible. Residents will receive prompt response by staff to resident needs within a timeframe reasonable to the circumstances. The Resident Care Director and the Executive Director are responsible for monitoring call bell response times to ensure call bells are responded to in a reasonable timeframe.
Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to implement its plan for medication management. Evidence: 1. Staff #1 provided a copy of the facility?s medication management plan labeled ?Handling, Ordering, and Refilling Medications (12/14/2020)? which indicated all physician ordered medications will be available for the resident. 2. February 2021 and March 2021 Medication Administration Records (MAR?s) documented staff did not administer the following medications due to refills needed and drugs not available: A. Resident #1?s Carvedilol 25mg and Amlodipine 5mg on 02-02-2021; Trazadone 50mg on 02-03-2021; Rosuvastatin 10mg and Montelukast 10mg on 02-08-2021 and 02-09-2021; and Carvedilol 25mg on 03-04-2021; B. Resident #2?s Levothyroxine 25mcg on 02-13-2021 and 02-15-2021; Nystatin Ointment 100000 unit/gm on 02-06-2021 through 02-08-2021, and 02-26-2021; Furosemide 20mg 02-10-2021, 02-12-2021, 02-17-2021, 02-18-2021, 02-20-2021 through 02-22-2021, 03-12-2021, and 03-15-2021 through 03-17-2021; Hydrocodone 325mg 02-06-2021, 02-07-2021, and 02-09-2020; Cranberry Cap 200mg 03-08-2021, 03-10-2021, 03-12-2021, 03-15-2021 through 03-17-2021; and Vitamin D3 on 03-16-2021; C. Resident #3?s Co Q-10 100mg on 02-12-2021 through 02-14-2021, Gabapentin 300mg on 02-08-2021, or Rosuvastatin 20mg on 02-12-2021 through 02-17-2021; D. Resident #4?s Metoprolol 25mg on 02-21-2021 and 02-22-2021, and Ferrous Sulfate 325mg on 02-26-2021; and E. Resident #5?s Melatonin 10mg on 02-13-2021 through 02-19-2021, and Trazadone 150mg on 03-03-2021 and 03-04-2021. 3. Staff #1 stated there was ?No documentation of physician being made aware of the resident?s missed medications? for the aforementioned residents. 4. ?Resident Council Concerns Checklist? form dated 02-11-2021 documented ?Resident stated [resident] asked med tech for [resident] medication. Med tech stated she did not have that medication on the cart and did not know how to order.?
Plan of Correction:	What Has Been Done to Correct? Usage of agency staff has been suspended. Routine in-servicing of the community?s medication management program and procedures for reordering medications has been implemented. Community has implemented cycled medication delivery through contracted pharmacy. How Will Recurrence Be Prevented? All new associates responsible for the administration of medication will be orientated to the community?s medication management plan, to include procedures for handling, ordering, and refilling medications. In-servicing and training on the community?s Medication Management Plan will be reviewed with associates responsible for the administration medication annually and as needed. Person Responsible: The Resident Care Director is responsible for ensuring that all associates responsible for the administration of medication are orientated to the community?s Medication Management Plan and the plan is reviewed at least annually.
Standard #:	22VAC40-73-650-A
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure no medications are discontinued by the facility without a valid order from a physician or other prescriber. Evidence: 1. Resident #4?s current signed physician?s orders dated 11-24-2020 documented ?Deep Blue Complex- 1 capsule twice daily for osteoarthritis.? 2. Resident #4?s January 2021 Medication Administration Record (MAR) documented the resident last received Deep Blue Complex on 01-27-2021. February 2021 and March 2021 MAR?s did not include documentation that the Deep Blue Complex was administered. 3. Staff #1 did not provide documentation that staff administered Deep Blue Complex to resident #4 from 01-28-2021 through 03-17-2021. 4. Staff #1 acknowledged the facility discontinued the aforementioned medication without a valid order from a physician or other prescriber.
Plan of Correction:	Order for dietary supplement was discontinued 11/19/20 in EMAR and was not administered from this date through inspection date. Evidence was provided at the time of inspection of communications between community associates, resident?s legal representative, and primary care physician regarding dietary supplement. PCP delayed order to confirm whether dietary supplement created increased risk of worsening another underlying health condition. Updated order was received for dietary supplement on 4/4/2021 documented ?Deep Blue Complex- 1 capsule one time per day everyday?. All current physician?s orders have been reviewed and signed to ensure residents are administered medication based on current and accurate orders from the physician. No medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the community without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, dietary supplement and sample medications. Physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. Physician's or other prescriber's oral orders will be reviewed and signed by a physician or other prescriber within 14 days. The Resident Care Director and Assistant Resident Care Director are responsible for ensuring that medications are started, changed, and/or discontinued after a valid order is received from a physician or other prescriber.
Standard #:	22VAC40-73-660-A
Complaint related:	No
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. On 03-24-2021 at approximately 12:00 PM, during a virtual tour of the special care unit, staff #1 approached an unlocked medication cart located at the nurses? station. 2. Staff #1 stated ?staff #3 [who was responsible for the medication cart] left the special care unit for approximately 10 to 15 minutes? while the medication cart was left unlocked and unattended by staff #3. 3. Staff #1 acknowledged the facility did not keep the medication storage cart was not locked.
Plan of Correction:	Associate has received in-service and training on the importance of keeping the med cart locked whenever the associate is not standing at the med cart preparing for administration of medications. The medicine cabinet, container, or compartment used for storage of medications and dietary supplements prescribed for residents will be utilized in a manner consistent with current standards of practice. 1. The storage area shall be locked and the individual responsible for medication administration shall keep the keys to the storage area on his person. The Resident Care Director (RCD) or designee will be responsible for ensuring that all associates responsible for the administration of medication will be in-serviced on current standards of practice regarding the storage of medications. The RCD or designee will conduct unscheduled audits to ensure medicine cabinets, containers, or compartments utilized for the storage of medications and dietary supplements are compliant with current standards of practice. The Executive Director will also conduct random unscheduled audits of medicine cabinets, containers, or compartments used for storage of medications and dietary supplements.
Standard #:	22VAC40-73-660-B
Complaint related:	No
Description:	Based on observation, record review, and interview, a resident was permitted to keep medications in their room and the Uniform Assessment Instrument (UAI) indicated that the resident was not capable of self-administering medication. Evidence: 1. On 03-24-2021, during a virtual tour of the facility with staff #1, the following medications were observed in residents? rooms: A. Tylenol 650mg, Miralax, Benadryl, Biofreeze, and Diclofenac topical gel in resident #1?s bathroom; B. A plastic pill cup containing an unidentified pink and yellow cream on resident #2?s nightstand, and Vicks Vapor rub, Fungi care anit-fungal liquid, and Stopain relieving roll-on in the resident?s bathroom; C. Lotemac eyedrops and Vitamin A&D ointment on resident #3?s bedside table, and Preparation H cream, Vicks Vapor rub, Fluocinonide topical solution, and Aspercreme in the resident?s bathroom. 2. Resident #1?s current UAI dated 12-01-2020, resident #2?s current UAI dated 11-16-2020, and resident #3?s current UAI dated 11-17-2020 documented medications are to be administered by a lay person and/or professional nursing staff. 3. Staff #1 observed and acknowledged that resident #1, resident #2, and resident #3 were not permitted to keep medications in their room for self-administration based on their current UAI?s.
Plan of Correction:	Education on current standards of practice regarding self-administration and storage of medications kept in the resident?s room has been implement with residents # 1, 2, & 3 and their families/legal representatives. Resident # 2 & #3 have received physician?s orders to keep specified medications in room to be stored in an out-of-sight location. Residents will be permitted to keep their own medication in an out-of-sight secured location within their room if the UAI has indicated that the resident is capable of self-administering medication. All medications and dietary supplements shall be stored so that they are not accessible to other residents. The Resident Care Director is responsible for ensuring the UAI & ISP indicate when resident is permitted to keep medications in their room and is based on the resident?s capability to self-administer medications. All associates administering medications are responsible for ensuring that a resident is only permitted to keep medication in their room if the UAI & ISP indicate that the resident is capable of self-administering medication.
Standard #:	22VAC40-73-680-C
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure medications are administered no earlier than one hour before and no later than one hour after the facility's standard dosing schedule. Evidence: 1. Staff #1 provided a copy of the facility?s standard dosing schedule labeled ?Medication Services? which indicated the resident?s Medication Administration Record (MAR) would identify the designated time of administration. 2. February 2021 MAR?s and ?Time Variance Report? documented the following scheduled administration times: A. Resident #1?s scheduled Montelukast 10mg and Trazadone 50mcg at 8:00 PM and Rosuvastatin 10mg at 9:00 PM was administered at 10:23 PM on 02-03-2021; and at 11:25 PM on 02-24-2021; B. Resident #2?s scheduled Amlodipine 5mg, Buspirone 10mg, and Preservision AREDS 2 at 11:40 PM on 02-24-2021; C. Resident #3?s scheduled Rosuvastatin at 9:00 PM was administered at 7:47 PM on 02-03-2021; at 7:37 PM on 02-14-2021; and D. Resident #5?s scheduled Certavite, Fish Oil 1000mg, Saw Palmetto 500mg, Tamsulosin 0.4mg, and Vitamin D3 25mcg at 10:30 AM was administered at 1:38 PM. 3. Staff #1 provided a copy of the ?Resident Council Concerns Checklist? dated 02-11-2021 and 03-19-2021 which documented, ?Medications are not being administered at appropriate times?? and ?Not receiving medications at the correct time.? 4. Staff #1 and staff #2 acknowledged the residents? aforementioned medications were not administered within the correct times.
Plan of Correction:	Usage of agency staff has been suspended. Routine audits of medication administration records are conducted to verify proper documentation of medication administration and compliance of administration of medication based on physician?s orders. Medications will be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Medications will be administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. The Resident Care Director is responsible for ensuring that medications are scheduled to be administered in accordance with physician?s orders. Resident Care Director or designee is responsible for ensuring that medication administration records are routinely reviewed to ensure compliance with standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record review and interview, the facility did not administer medications in accordance with the physician's instructions. Evidence: 1. Resident #2?s current signed physician?s orders dated 12-29-2020 documented, ?Furosemide 20mg- Take one tablet by mouth on Mon/Wed/Fri for CHF [Congestive Heart Failure].? 2. Resident #2?s January 2021 and February 2021 Medication Administration Record (MAR) documented staff administered Furosemide 20mg on the following days: A. Thursday: 01-28-2021, 02-04-2021, and 02-11-2021; B. Saturday: 01-30-2021, 02-06-2021, and 02-13-2021; C. Sunday: 01-31-2021, 02-07-2021, and 02-14-2021; and D. Tuesday: 02-02-2021, 02-09-2021, and 02-16-2021. 3. Staff #1 could not provide a physician?s order documenting a change in the administration of resident #2?s Furosemide 20mg to daily and stated there are ?No signed orders after 12/29/2020.? 4. Staff #3 was asked about the administration of resident #2?s Furosemide 20mg, and stated ?not having access to MD [physician?s] orders to review for accuracy. If medication was documented on other days, it was because it popped up on the screen for staff to administer.? 5. Resident #1?s signed physician?s order dated 02-02-2021 documented, ?Acyclovir 400mg- 1 (one) Tablet by mouth three times daily for Cold sore; 7 day supply.? 6. Resident #1?s February 2021 MAR documented staff administered the first dose of Acyclovir 400mg at 7:30 AM on 02-03-2021. The last dose scheduled for 02-09-2021 at 7:30 PM was not administered. 7. Staff #1 stated the physician was not made aware of resident #1?s missed dose of Acyclovir 400mg, and 8. Staff #1 acknowledged resident #1 and resident #2?s aforementioned medications were not administered in accordance with the physician?s instructions.
Plan of Correction:	All current physician?s orders have been reviewed and signed to ensure residents are administered medications based on current and accurate orders from the physician. Training on how to properly configure medications in the EMAR system to match physician?s orders has been executed. In-services on routine checks of physician?s orders in the EMAR system against the medications has been implemented. No medication, dietary supplement, diet, medical procedure, or treatment shall be administered, changed, or discontinued by the community without a valid order from a physician or other prescriber. Missed medications will be documented and communicated with resident?s primary care physician or prescriber. The Resident Care Director and Assistant Resident Care Director are responsible for ensuring that medications are started, changed, and/or discontinued after a valid order is received from a physician or other prescriber.
Standard #:	22VAC40-73-680-E
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure treatments ordered by a prescriber are provided according to his instructions and documented. Evidence: 1. Resident #2?s current signed physician?s orders dated 12-29-2020 documented, ?Weigh once weekly on Tuesday.? 2. Resident #2?s Tuesday weekly weights were not documented on the January 2021 Medication Administration Record or Treatment Administration Record. 3. Staff #1 provided documentation of resident #2?s monthly weights labeled ?Vital signs due by the 10th of every month? for the month of January 2021; however, the form only documented the resident was weighed once for the month. 4. Staff #1 did not provide additional documentation of resident #2?s weights being taken every Tuesday in January 2021. 5. Staff #1 did not provide a physician's order to discontinue the weekly weights. 6. Staff #1 acknowledged resident #2 was not weighed weekly by staff every Tuesday as ordered.
Plan of Correction:	What Has Been Done to Correct? Resident #2?s weights are documented monthly, consistent with physician?s orders dated 2/9/2021 and current physician?s orders dated 3/2/2021. How Will Recurrence Be Prevented? Medical procedures or treatments ordered by a physician or other prescriber will be provided according to his instructions and documented. Person Responsible: The Resident Care Director, or designee, is responsible for ensuring resident weights are documented monthly or as prescribed by residents? physician.
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. February 2021 MAR?s did not include the initials of direct care staff administering the following medications: A. Resident #1?s Rosuvastatin 10mg at 8:00 PM, and Montelukast 10mg and Trazadone 50mg at 9:00 PM on 02-10-2021 and 02-14-2021; B. Resident #3?s Gabapentin 300mg and Rosuvastatin 20mg at 9:00 PM on 02-23-2021; and C. Resident #4?s Acetaminophen 500mg, Pravastatin 10mg, and Losartan 100mg at 9:00 PM on 02-23-2021. 2. Staff #1 acknowledged the aforementioned dates did not include the initials of the direct care staff who administered the medications.
Plan of Correction:	Usage of agency staff has been suspended. Routine audits of medication administration records are conducted to verify proper documentation of medication administration and compliance of administration of medication based on physician?s orders. Medications will be administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. At the time the medication is administered, the community will document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements. The MAR will include: 1. Name of the resident; 2. Date prescribed; 3. Drug product name; 4. Strength of the drug; 5. Dosage; 6. Diagnosis, condition, or specific indications for administering the drug or supplement; 7. Route (e.g., by mouth); 8. How often medication is to be taken; 9. Date and time given and initials of direct care staff administering the medication; 10. Dates the medication is discontinued or changed; 11. Any medication errors or omissions; 12. Description of significant adverse effects suffered by the resident; 13. For "as needed" (PRN) medications: a. Symptoms for which medication was given; b. Exact dosage given; and c. Effectiveness; and 14. The name, signature, and initials of all staff administering medications. The Resident Care Director is responsible for ensuring medications are administered in accordance with physician?s orders. Resident Care Director or designee is responsible for ensuring that medication administration records are routinely reviewed to ensure compliance with standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing and contain initials of direct care staff administering the medication. The Executive Director is responsible for conducting random audits of MAR to ensure compliance with regulatory standard.