VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Front Royal
600 Mount View Street
Front royal, VA 22630
(540) 636-2800

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: Nov. 1, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

A monitoring inspection was completed remotely on 11/01/2021 and onsite on 11/17/2021. A tour was completed and the facility was clean and free from any foul odors. All required postings were visible. Four staff and four resident records were reviewed. The activities calendar and lunch menu were observed. There were 6 violations during this monitoring inspection. Details of non-compliance can be viewed in the violation notice section of this report. Upon receipt of this violation notice, a plan of correction is requested for each violation. The plan of correction should include: 1) steps to correct non-compliance; 2) Measure(s) to prevent reoccurrence of non-compliance; 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s); 4) The date by which the non-compliance will be corrected. If you have any questions regarding this inspection, please contact the licensing inspector at (540) 292-5932 or rhonda.whitmer@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on a review of resident's records, the facility failed to obtain prior to admission, an assessment indicating the resident as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize his own safety and welfare. EVIDENCE: The serious cognitive impairment assessment form for resident 2, dated 10/01/2021 indicates resident does not have a primary diagnosis of dementia and has the ability to recognize danger or protect his own safety and welfare.
Plan of Correction:	Resident 2 has been seen by Community medical staff and has diagnosed the resident with dementia. Executive Director or designee will review every resident's diagnosis prior to admission into the locked Memory Care unit to ensure compliance. All MC charts have been audited for a diagnosis of dementia.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to have a comprehensive individualized service plan within 30 days after admission that included the required components. EVIDENCE: 1. The Uniform Assessment Instrument (UAI) for resident 1, dated 11/03/2021 indicates resident requires physical and mechanical assistance with dressing, toileting, and transferring. The Individualized Service Plan (ISP) dated 03/09/2021 does not identify the mechanical supports required for dressing and that physical assistance is needed with toileting and transferring. 2. Resident 2 has a DNR on file dated 10/09/2021. The ISP indicates resident is a full code. 3. There was no comprehensive individualized service plan on file for resident 2 who was admitted on 10/06/2021.
Plan of Correction:	New comprehensive individualized service plans have been created for resident 1 and 2. Resident Care Director or designee will audit ISPs and UAIs for new residents.
Standard #:	22VAC40-73-640-A
Description:	Based on review of facility medication management plan, the facility failed to implement procedures to ensure each resident's prescription drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. EVIDENCE: 1. Page 5 #6e of the facility medication management plan indicates if a medication is not available from the facility pharmacy, backup pharmacy will be utilized to ensure medication is available as indicated in the facility disclosure statement. 2. Resident 1 has the following order: Polytrim Ophthalmic Solution-Instill one drop in each eye four times daily for seven days for Conjunctivitis. 3. Documentation on the Medication Administration Record (MAR) for resident 1 indicates medication was not available for administration on 11/12/2021 at 12:00pm and 6:00pm; 11/13/2021 at 6:00am. 12:00pm and 6:00pm; 11/14/2021 at 12:00am, 6:00am, 12:00pm and 6:00pm; 11/15/2021 at 12:00am, 6:00am, 12:00pm and 6:00pm.
Plan of Correction:	Resident's 1 medication has been received from the pharmacy. Resident Care Director or designee will ensure compliance by checking medication availability with the pharmacy and if medications are unavailable, they will be received from the backup pharmacy. Nursing staff will be re-educated on ensuring medication availability.
Standard #:	22VAC40-73-680-D
Description:	Based on review of resident's records, the facility failed to ensure medications are 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. EVIDENCE: 1. Resident 1 has the following order: Polytrim Ophthalmic Solution-Instill one drop in each eye four times daily for seven days for Conjunctivitis. 2. Documentation on the Medication Administration Record (MAR) for resident 1 indicates medication was not available for administration on 11/12/2021 at 12:00pm and 6:00pm; 11/13/2021 at 6:00am. 12:00pm and 6:00pm; 11/14/2021 at 12:00am, 6:00am, 12:00pm and 6:00pm; 11/15/2021 at 12:00am, 6:00am, 12:00pm and 6:00pm. 3. Resident 2 has the following order: Metoprolol Tartrate 25mg-Take 1/2 tablet by mouth two times per day at 9:00am and 9:00pm; Obtain and record blood pressure prior to giving medication. Hold for systolic blood pressure less than 100 or pulse less than 60. 4. Documentation in the Medication Administration Record (MAR) indicates medication was administered to resident 3 on 11/03/2021 at 9:00am and resident's pulse is recorded as 56.
Plan of Correction:	Resident Care Director re-educated RMA staff on medication administration and following prescribed orders as received. Resident Care Director or designee will randomly check the MAR weekly to ensure medications are administered in accordance with the prescriber's instructions and consistently with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.
Standard #:	22VAC40-73-860-I
Description:	Based on direct observation, the facility failed to ensure cleaning supplies and other hazardous materials are in a locked area. EVIDENCE: During a walk though of the facility, an unlocked, unattended housekeeping cart with multiple cleaning agents was observed in the hallway of the second floor.
Plan of Correction:	The housekeeping cart has been locked and housekeeping staff will be re-educated on keeping unoccupied carts containing hazardous materials locked at all times. The Executive Director will spot check housekeeping carts weekly to ensure compliance throughout the community.
Standard #:	22VAC40-90-40-B
Description:	Based on review of residents' records, the facility failed to obtain a criminal history report on or prior to the 30th day of employment. EVIDENCE: The criminal history report for staff 4, hired on 04/12/2021 is dated 11/02/2021.
Plan of Correction:	The criminal history report for staff 4 has been received. The Executive Director will audit new employee's files weekly to ensure compliance.