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: June 30, 2022

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 63.2 GENERAL PROVISIONS 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION

Technical Assistance:

22VAC40-80-120-2 Required Postings

Comments:

An unannounced renewal inspection was initiated and completed on 6/30/22- from 9:00 a.m. until 4:11p.m. Number of residents present at the facility at the beginning of the inspection: 78 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 5 Number of interviews conducted with residents: 6 Number of interviews conducted with staff: 3 Observations by licensing inspector: Medication pass, Activities, Dinning and Resident?s room. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Toby Hursey, Licensing Inspector at (757) 670-0472 or by email at Toby.Hursey@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-210-G
Description:	Based on review of staff record and interview with staff, facility failed to ensure that direct care staff who are licensed health care professionals or certified nurse aides shall attend at least 12 hours of annual training. Evidence: Staff #9 (DOH is12/15/18), training record contained documentation of 8.5 hours of annual training.
Plan of Correction:	Staff #9 has now completed 12 hours of annual training. All current direct care staff members have been audited to ensure that they have completed 12 hours of annual training. The Business Office Manager will do a quarterly audit on direct care staff training hours and ensure that 12 hours are completed yearly for each direct care staff member
Standard #:	22VAC40-73-260-C
Description:	Based on review of staff record and interview with staff, facility failed to ensure that direct care staff who are licensed health care professionals or certified nurse aides shall attend at least 12 hours of annual training. Evidence: Staff #9 (DOH is12/15/18), training record contained documentation of 8.5 hours of annual training.
Plan of Correction:	The listing of CPR and First Aid certified staff members is now posted in the Assisted Living Nurses Station and the Memory Care Nurses Station and indicates whether the staff persons are first aid or CPR certified or both. The Business Office Manager will update the current list after each CPR and First Aide certification/recertification class is offered and after each hire to assure the list is current and up to date. The list will remain posted in each nurse?s station. The Business Office Manager will conduct a monthly audit to assure that correct CPR/First Aid certification information is accurate
Standard #:	22VAC40-73-450-C
Description:	Based on review of resident records the facility failed to ensure the comprehensive individualized service plan (ISP) shall include the following: description of identified needs and date identified based upon the Uniform Assessment Instrument (UAI). Evidence 1. Resident?s #1(UAI) dated for 12/1/2021 indicates that that resident is incontinent of bowl less than weekly. The (ISP) dated 6/1/2022 indicates that resident is continent of bowel 2. The UAI dated 11/02/21 for resident #1 is documented ?yes? for needs helps in the area of dressing. ?Mechanical help only? is checked for dressing. The ISP dated 11/02/21 documents resident does not require assistance with dressing.? The UAI and ISP are inconsistent with documenting the resident needs in the area of dressing. 3. The UAI dated 11/02/21 for resident #1 is documented ?yes? for needs helps in the area of transferring. ?Mechanical help only? is checked for transferring. The ISP dated 11/02/21 documents ?resident does not require assistance with transferring.? The UAI are inconsistent with documenting the resident needs in the area of transferring. 4. The UAI dated 05/21/22 for resident #2 documents ?yes? for needs help in the area of toileting. ?Mechanical & Human help? for physical assistance 2? is checked for toileting. The ISP dated 06/12/22 does not document any description of needs and services to be provided for toileting. 5. The UAI dated 05/21/22 for resident #2 is documented ?yes? for needs help in the area of transferring. ?Mechanical help only? is checked for transferring. The ISP dated 06/12/22 does not document any description of needs and services to be provided for transferring.
Plan of Correction:	Resident #1?s UAI and ISP are now consistent for the area of ?continence of bowel and bladder.? Resident is continent of bowel and this is now reflected as such on both the UAI and ISP. Resident #1?s UAI and ISP now match showing that resident needs ?mechanical help only? regarding dressing. Resident #1?s UAI and ISP now match for the area of ?transferring? and now shows that resident needs ?mechanical help only? when transferring. The UAI and ISP for Resident #2 now match showing that Resident #2 needs ?mechanical help only? when toileting. Also, Resident #2?s UAI and ISP has been corrected to reflect resident needs ?mechanical help only? with regard to transferring. In addition, the RCD and ARCD will assure that the UAI and ISP showing matching information. Prior to resident?s admission, and each time a UAI or ISP is completed, the ARCD and RCD will compare the UAI and ISPs for consistency prior to adding them to the resident?s medical record. On 7/2/22, RCD/ARCD were retrained on the importance of the UAI and ISP containing matching information reflecting the needs of each resident. The RCD and ARCD will audit the ISP against the UAI each time an ISP is entered into the system and prior to placing documents on the resident?s medical record. RCD and ARCD will use an audit sheet to compare documents. The RCD and ARCD will also conduct a quarterly audit of all ISPs to assure that there is conformity to the UAIs of each resident.
Standard #:	22VAC40-73-680-D
Description:	Based on the onsite observation and record review the facility failed to ensure medications are administered according to the physician?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1.During the medication pass June 30, 2022, the Licensing Inspector (LI) observed staff #1 administer the following medications crushed in applesauce to resident #1: acetaminophen, anastrozole, atenolol, furosemide, andlisinopril. The physician orders for resident #1 do not include documentation stating the aforementioned medications should be crushed before administration. 2. Per the Physician order dated 06/19/22 for resident #1 the prescription for Xarelto from 20mg to 15mg, 1 tablet by mouth every day. Per Staff #1 the medication for Xarelto was not present in the medication cart to be administered to the resident. The Medication Administration record (MAR) for June 2022 did not document a change or update to the MAR to identify thechange in the dosage of Xarelto from 20mg to15mg. 3. The physician order for the medication, Polyeth Glyc Powder document medication to be ?mixed 17 Grams in 8 oz of water.? Staff #1did not have a measurement tool to accurately measure 8oz of water. Per staff #1 the facility only has cups that accurately measure 5oz of water. 4. LI observed staff #1estimate 8 oz. of water using two 5 oz. measuring cups.
Plan of Correction:	On July 5, 2022, staff member #1 was retrained regarding the crushing of medications per the standards of practice outlines in the Va. Board of Nursing medication aide curriculum. Resident #1?s medication orders were verified and do not include the crushing of medications. Resident #1?s medication was verified to confirm that the dosage of Xarelto for resident #1 was changed to 15mg. POA of resident was notified of this mistake and correction. Resident is now receiving 15mg. of Xarelto per the physician?s order. In addition, the community now has the proper cup size (8 oz) for the water to mix Resident #1?s Polyeth Glyc Powder. All RMAs were retrained on 7/6/22 regarding the crushing of medications and proper measuring of water per The Va. Board of Nursing medication aide curriculum. CSL Eastern Shore purchased 8 oz. cups for proper administration of resident medications. In addition, CSL Eastern Shore now has a medication scanner that will not ?check off? a medication in the system unless it is given per physician?s order. All staff were trained on the new medication scanner on 8/10/22.