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: April 27, 2021 , April 29, 2021 , April 30, 2021 , May 3, 2021 and May 4, 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 BUILDING AND GROUNDS 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 renewal inspection was initiated on 04-27-2021 and concluded on 05-04-2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 39. 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-compliance's with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review and interview, the facility failed to ensure the resident?s admission physical examination included a description of reactions to any known allergies. Evidence: 1. Resident #1?s ?Resident Physical Examination Report? dated 02-23-2021 did not include documentation of a description of the allergic reaction to Zolpidem. 2. Resident #3?s ?Resident Physical Examination Report? dated 02-04-2021 did not include documentation of a description of the allergic reaction to Keflex and PCN [Penicillin]. 3. Staff #1 acknowledged the residents? admission physical examinations did not include the aforementioned required information.
Plan of Correction:	Resident?s ISP has been updated to reflect ?Unknown? reaction to medication based on interview with the resident and resident?s legal representative. All resident records have been audited to ensure documentation of reactions to allergies. Clinical team is in communication with residents/legal representatives/PCPs to obtain information regarding reactions to any known allergies. Within the 30 days preceding admission, a person will have a physical examination by an independent physician. The report of such examination will be on file at the assisted living facility and will contain the following: 1. The person's name, address, and telephone number; 2. The date of the physical examination; 3. Height, weight, and blood pressure; 4. Significant medical history; 5. General physical condition, including a systems review as is medically indicated; 6. Any diagnosis or significant problems; 7. Any known allergies and description of the person's reactions; 8. Any recommendations for care including medication, diet, and therapy; 9. Results of a risk assessment documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it; 10. A statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H; 11. A statement that specifies whether the individual is considered to be ambulatory or non-ambulatory as defined in this chapter; 12. A statement that specifies whether the individual is or is not capable of self-administering medication; and 13. The signature of the examining physician or his designee The Resident Care Director and the Executive Director are responsible for reviewing the physical examination report and ensuring all required information is documented on the report.
Standard #:	22VAC40-73-325-C
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 03-26-2021 and resident #3?s UAI dated 04-20-2021 documented the residents meet criteria for assisted living level of care. 2. Staff ?Progress Notes? indicated the following falls: A. 03-01-2021, resident #1 fell during the late night hour of 02-28-2021, due to fall resident was sent out to the hospital; B. 04-01-2021, resident #3 became unsteady on feet, fell in the common area, and was sent out to the hospital; 3. Staff #1 did not provide documentation of an analysis of the circumstances of the fall for resident #1 and resident #3. 4. Staff #1 acknowledged the facility did not document an analysis of the circumstances of the falls for residents? #1 and #3.
Plan of Correction:	Fall Analysis has been developed and implemented for any resident who sustains a fall. At the time the comprehensive ISP is completed, a written fall risk rating will be completed. The fall risk rating will be reviewed and updated under each of the following circumstances: 1. At least annually; 2. When the condition of the resident changes; and 3. After a fall. When a resident falls, the community will show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls. The Resident Care Director is responsible for ensuring a fall analysis is completed for each resident who sustains a fall. The Executive Director is responsible for reviewing the fall analysis after each fall
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 current Uniform Assessment Instrument (UAI) dated 03-26-2021 documented the need for mechanical and physical assistance with bathing, mechanical assistance with supervision with mobility, and mechanical assistance with wheeling. The current ISP dated 03-26-2021 did not include documentation of the type of mechanical device needed for bathing and mobility, nor the need for mechanical assistance with mobility. 2. Resident #3?s current UAI dated 04-20-2021 documented the need for physical assistance with wheeling; however, the current ISP dated 04-20-2021 did not include the need for wheeling. In addition, the ?Resident Physical Examination Report? dated 02-04-2021 documented the resident?s code status ?DNR? [Do Not Resuscitate]; however, the ISP documented a Full Code status. 3. Staff #1 acknowledged the aforementioned ISP?s did not include a description of the residents identified needs, and the discrepancy with the code status.
Plan of Correction:	UAIs/ISPs for both Residents? #1 & #3 have been updated to reflect the needs of the residents. All residents? UAIs/ISPs are being reviewed to ensure consistency between the two regarding residents? documented needs. Health Care Oversight has been completed by Regional Nurse Consultant to include a summary of items to review. On 6/16/21, ED, RCD, and ARCD will review all updated UAIs/ISPs to ensure they are cohesive and include a detailed description of resident needs. Explanation was provided during the time of inspection stating the community requests all residents who desire a DNR status to submit a Durable DNR consistent with Code of Virginia ? 54.1-2987.1. Resident #3?s physical examination report did not have a Durable DNR attached and verification of resident/legal representative?s desire for DNR was not produced. When the community spoke with the resident?s legal representative regarding the DNR status, it was communicated that there was no interest in a DNR status and the resident was then listed as a Full Code, evident by her signed ISP. All residents will be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition. The comprehensive individualized service plan will include the following: 1. Description of identified needs and date identified based upon the UAI, admission physical examination, interview with resident, fall risk rating, if appropriate, assessment of psychological, behavioral, and emotional functioning, and other sources. The Resident Care Director is responsible for ensuring resident?s UAI and ISP reflect accuracy relating to resident?s needs and preferences. The Resident Care Director and the Assistant Resident Care Director are responsible for ensuring resident UAI/ISP are completed at the time of admission, every 6 months, and when the resident experiences a change of condition.
Standard #:	22VAC40-73-640-A
Description:	Based on record review and interview, the facility failed to implement its medication management plan ?Handling, Ordering, and Refilling Medications (12/14/2020)? to ensure each resident's medications are refilled in a timely manner. Evidence: 1. Staff #1 provided a copy of the facility?s medication management plan which indicated all physician ordered medications will be available for the resident. 2. Resident #1?s April 2021 Medication Administration Record documented staff did not administer Tamsulosin on 04-04-2021, 04-05-2021, and 04-07-2021, Allergy Relief on 04-13-2021, 04-14-2021, 04-17-2021 through 04-19-2021, 04-23-2021, 04-26-2021, and 04-27-2021, Vitamin D3 on 04-13-2021, 04-20-2021, and 04-21-2021, and Vitamin B-12 on 04-04-2021, 04-05-2021, and 04-18-2021 through 04-20-2021 due to refill needed and drug not available. 3. Staff #1 acknowledged resident #1?s aforementioned medications were not refilled in a timely manner to avoid missed dosages.
Plan of Correction:	Evidence was provided revealing the medication aides? routine follow-up with the pharmacy to refill the medication. The medication aides overlooked the requirement to address this issue with management after multiple unsuccessful attempts at obtaining the medication refill. All staff authorized to administer medications were in-serviced by Regional Nurse Consultant on the community?s medication management program, to include reordering medication from the pharmacy. The Regional Nurse Support Specialist, the Executive Director and Resident Care Director are in regular communication with the community?s partnering pharmacy regarding concerns relating to timely refills of medications. All staff authorized to administer medications will be in-serviced on and observe the community?s ?Handling, Ordering, & Refilling Medications? policy. When a fill is requested and not received or an error is found, staff authorized to administer medications will notify the pharmacy/Resident Care Director/Designee immediately. The Resident Care Director and the Assistant Resident Care Director are responsible for ensuring medications are refilled in a timely manner. Medications that have been ordered from the pharmacy and are not delivered in a timely manner will be addressed with the pharmacy by the Resident Care Director/Assistant Resident Care Director and/or the Executive 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. The residents signed physician?s orders did not include a diagnosis or specific indications for administering the following medication: A. Resident #1?s order dated 04-09-2021 for Celexa 10mg and Olanzapine 2.5mg; and B. Resident #2?s order dated 04-08-2021 for Clotrimazole 10mg. 2. Staff #1 acknowledged resident #1 and resident #2?s aforementioned prescriber?s orders did not include the diagnosis or specific indications for administering the medications.
Plan of Correction:	All physician?s orders are being reviewed, updated, and signed to include a diagnosis for all medications. Physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements will 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. The Resident Care Director and the Assistant Resident Care Director are responsible for ensuring physician?s orders include a diagnosis.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview, the facility did not administer medications in accordance with the physician?s instructions. 1. Resident #2?s signed physician?s order dated 04-08-2021 documented ?Clotrimazole 10mg Lozenge- Dissolve 1 tablet in mouth four times daily.? 2. Resident #2?s April 2021 Medication Administration Record documented staff did not administer Clotrimazole 10mg on 04-14-2021 through 04-26-2021 due to the medication being held. 3. Staff #1 did not provide a physician?s order to hold Clotrimazole10mg on 04-14-2021 through 04-26-2021 and stated there was ?No order to hold located.? 4. Staff #1 acknowledged resident #2's Clotrimazole 10mg was not administered in accordance with the physician's instructions.
Plan of Correction:	What Has Been Done to Correct? Resident # 2 discharged from the community on 4/24/21. Clotrimazole was held after resident?s oncologist gave a verbal order to discontinue (d/c). Medication was held awaiting formal written discontinue order from oncologist. Resident Care Director (RCD) had several conversations with resident?s oncology office and sister regarding the need for d/c order but was having trouble obtaining orders from the oncologist. How Will Recurrence Be Prevented? No medication, dietary supplement, diet, medical procedure, or treatment will be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications. The resident's record will contain the physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's oral order. Orders will be organized chronologically in the resident's record. New orders will be reviewed and signed by a physician or other prescriber within 14 days. Person Responsible: The Resident Care Director and the Assistant Resident Care Director (ARCD) are responsible for ensuring medications are administered in compliance with physician?s orders. The RCD is responsible for ensuring that all oral orders are documented and signed by the physician within 14 days.
Standard #:	22VAC40-73-680-E
Description:	Based on record review and interview, the facility failed to ensure treatments ordered by a physician or other prescriber are provided according to his instructions and documented. The documentation was not maintained in the resident's record. Evidence: 1. Resident #2?s signed physician?s order dated 04-07-2021 documented ?Humalog Kwikpen Solution Pen-Injector 100mg inject as per sliding scale? 401+ = 10 units Recheck BS in 1 hour, Notify MD. 2. Resident #2?s April 2021 Medication Administration Record documented blood sugar readings of 426 on 04-20-2021 at 9:00 PM, and 486 on 04-23-2021 at 11:00 AM. There was no documentation indicating 10 units of insulin was administered; blood sugars were rechecked in 1 hour; or the physician being notified of the blood sugar readings. 3. Staff #1 did not provide documentation of the number of units of insulin administered to resident #2, the blood sugars being rechecked on the aforementioned dates, or that the physician was made aware of the aforementioned blood sugar readings. Staff #1 stated ?No written documentation located.?
Plan of Correction:	The Executive Director (ED) reached out to the organization?s technical support team to inquire as to why the requirement to input the administered units of insulin in the EMAR was not automatically populating during the administration of insulin, as designed. The technical support team identified an issue with the system configuration and has corrected the issue. The ED, RCD, and ARCD received virtual training on how to properly configure insulin medications in the EMAR in the event of future system malfunctions. Medical procedures or treatments ordered by a physician or other prescriber will be provided according to his/her instructions and documented. The documentation will be maintained in the resident's record. The (E)MAR will include: Prescribing provider, 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, the diagnosis/ condition, and/or specific indications for administering each drug. Residents receiving insulin injections will have the proper EMAR configuration, including the requirement to document the number of insulin units administered during medication administration. The Resident Care Director and the Assistant Resident Care Director are responsible for ensuring medications are administered in compliance with physician?s orders. The Resident Care Director and the Assistant Resident Care Director are responsible for ensuring any resident with a diagnosis of diabetes mellitus receiving insulin injections has the proper EMAR configuration, including a requirement to document the number of insulin units administered during medication administration.