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: Jan. 19, 2023

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 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

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 01/19/23 from 8:30 am to 5:20 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 12/30/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 5 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: An observation and review of all medication carts in the assisted living and safe secure unit was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-40-B
Description:	Based on the onsite staff record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each staff person. Evidence: 1. The record for staff # 4, date of hire 09/21/21, contains a criminal history record report dated 12/21/21.
Plan of Correction:	Current employee files will be audited to assure compliance of regulation by Business Office Manager. New hires will not start with community (to include initial onboarding) until criminal history record report is received by Business Office Manager and approved by ED/designee. Business Office Manager will communicate with Executive Director in event criminal history record report is not received in a timely manner.
Standard #:	22VAC40-73-640-A
Description:	Based on observation the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated medications, methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes, methods to ensure the staff who are responsible for administering medications are adequately supervised, including periodic direct observation of medication administtration, and a plan for proper disposal of medication. Evidence: 1. The record for resident #1 contains a controlled substance count sheet for the resident?s Oxycodone medication. The count sheet documents Oxycodone was administered to the resident daily from 12/18/22 through 12/29/22. However, the MAR documents Oxycodone was only administered to the resident on 12/29/2022 and the resident was out of the facility on 12/24/22 and 12/25/22. The Count sheet and MAR for Dec. 2022 are inconsistent with one another in documenting when Oxycodone was administered. 2. During review of Resident?s #2 controlled substance count sheet for Morphine Syringes. The count sheet documented 30 available syringes. A count completed with staff #1, counted 28 available syringes on the medication cart. The count sheet was not accurate in documenting the number of syringes. 3. During observation with Staff #1 the following expired medication was observed on the medication cart: Dextromethorphan SUS 30 mg expired 09/2022 for resident # 3. 4. During an observation with staff # 2 a bag of prescription labeled and over the counter medications were located in an unlocked cabinet in the medication aide office/area. Staff # 1 and staff #2 stated the medications belonged to residents who were discharged from the facility. Staff # 1 and staff #2 were not able to provide information on the plan for proper disposal of these medications.
Plan of Correction:	Direct care staff administering medications have been re-in-serviced on organization?s Medication Management Policy to include completion of accurate controlled substance counts when assigned medication staff changes. ED, RCD, and RCC have reviewed the Standards for Licensed Assisted Living Facilities to be used as a reference to ensure regulatory compliance relating to medication management. The ED will continue to monitor progress. For the next 30 days, from 2/7/2023, the RCD or Designee will complete controlled substance counts with staff administering medications at a minimum of 3 times a week (One on each shift). The RCD or designee will then complete regular, random controlled substance counts with each shift at least monthly and as needed. RCD or Designee will conduct weekly audits on each medication cart to assure expired medications have been appropriately removed from the cart. RCD or Designee will complete medication pass audits with current staff administering medications within 30 days of 2/7/2023. Moving forward the RCD/designee will complete medication pass audits with new medication staff prior to working alone on medication cart, periodically and as needed to meet regulatory standards. ED will conduct regular, random medication pass audits, to include controlled substance counts, at least semi-annually on current staff who administer medications to include RCD and RCC. ED, RCD, RCC and new/current staff administering medications will review and document receipt of company policy regarding proper disposal of medication.
Standard #:	22VAC40-73-680-B
Description:	Based on observation the facility failed to ensure medications shall remain in the pharmacy issued container, with the prescription label or direction labeled attached, until administered to the resident. Evidence: 1. During the medication cart observation with staff #1, one round unmarked white pill was located in a pill cup in the first drawer and four round unmarked white pills were located in the fourth drawer. There were a total of five pills that were not in a pharmacy issued container and were not labeled in the drawers on the medication cart.
Plan of Correction:	Direct care staff administering medications have been re-in-serviced on organization?s Medication Management Policy to include medication is to remain in an appropriately labeled container until medication is to be passed resident. Pharmacy Audit and review conducted following unannounced visit. Medications not meeting the regulation standard have been removed from the medication cart. The ED will coordinate a Pharmacy Audit and Review to be conducted following unannounced visit. (Completed 1/24/23) Staff member #4 passing medication during Licensing Inspector visit will complete 4-hour Medication Aide Refresher course within 30 days of 2/7/2023. RCD or Designee will conduct weekly audits on each medication cart to ensure that medications are maintained in appropriately labeled medication container until administered to resident.