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: March 30, 2023

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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

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 03/30/2023 from 9:15 am until 5:30 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed: 6 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for five residents. The following were reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None 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. 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 #:	22VAC40-73-1090-A
Description:	Based on the record review the facility failed to ensure prior to admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. The record for resident #5 contains an assessment of serious cognitive impairment dated 12/02/2020 which includes a response of ?No? for the questions: does the individual have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia; is the individual unable to recognize danger or protect his/her own safety and welfare. 2. The record for resident #5 contains an approval for placement in a safe, secure environment dated 12/15/2020. The record documents a safe secure unit admission date of 12/16/2020.
Plan of Correction:	What Has Been Done to Correct? Resident #5?s record now has an assessment of serious cognitive impairment signed by her PCP. How Will Recurrence Be Prevented? The Resident Care Director and Assistant Resident Care Director were retrained by Executive Director on 43/23 on the importance of assuring the assessment of serious cognitive impairment form be signed prior to an admission to the safe, secure environment. The Resident Care Director and Assistant Resident Care Director were retrained by Executive Director on 4/3/2023 on utilizing the checklist to assure that appropriate, regulatory required paperwork has been reviewed prior to admission to safe, secured environment. In addition, an audit of resident files for completion of the Serious Cognitive Impairment forms for new and current residents in the safe, secure environment was completed on 4/10/2023 by the Assistant Resident Care Director. For the next 30 days, the Executive Director will review admission paperwork for residents being admitted to safe, secured environment to assure appropriate paperwork has been received and is correct. Person Responsible: Resident Care Director/Assistant Resident Care Director/Executive Director
Standard #:	22VAC40-73-250-D
Description:	Based on the record review the facility failed to ensure each staff person required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as evidence by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. The record for staff # 3, hire date 11/21/22, contains documentation of a risk assessment for TB completed 03/02/2022. The record does not contain documentation of a risk assessment for TB completed on or 7 days prior to the staff?s hire date of 11/21/22.
Plan of Correction:	What Has Been Done to Correct? A risk assessment was completed on staff member #3 on 3/31/23 which shows that staff member is free from tuberculosis. How Will Recurrence Be Prevented? The Business Office Manager was retrained by the Executive Director on following the new hire checklist which includes ensuring each staff member is evaluated annually for tuberculosis. An audit of new and current employee files was completed on 4/8-4/9/2023 and files reviewed are complete for documentation of tuberculosis screenings. Person Responsible: Business Office Manager/Executive Director
Standard #:	22VAC40-73-320-A
Description:	Based on the record review the facility failed to ensure within 30 days preceding admission, a person shall have results of a risk assessment documenting the absence of TB 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. Evidence: 1. The record for resident # 6, admission date of 03/09/2023, did not contain documentation of a risk assessment for TB.
Plan of Correction:	What Has Been Done to Correct? A risk assessment was completed on resident #6 on 3/31/23 which shows that resident is free from tuberculosis. How Will Recurrence Be Prevented? The Resident Care Director and Assistant Resident Care Director were retrained by the Executive Director on 4/3/23 on following the new resident checklist which includes ensuring each resident be assessed for the absence of tuberculosis and complete the current screening forms. The Resident Care Director and Assistant Resident Care Director audited new and current resident files on 4/8 and 4/9/2023 to assure that appropriate screening for tuberculosis has been completed. Moving forward, prior to admission the Resident Care Director/designee will assure that screening for tuberculosis has been completed and available at time of admission. For the next 60 days, the Executive Director/designee will complete an audit of new admissions to assure TB screening has been completed and appropriately documented on a form consistent with screening form published by the Virginia Department of Health . Person Responsible: Resident Care Director/Assistant Resident Care Director/Executive Director
Standard #:	22VAC40-73-450-C
Description:	Based on the record review the facility failed to ensure the Comprehensive Individualized Service Plan (ISP) shall be completed within 30 days after admission and shall include a description of identified needs based upon the UAI and other sources. Evidence: 1. The record for resident #3, admission date 07/28/22, contains a Preliminary ISP dated 07/28/22 and an ISP dated 09/28/22. The record does not contain an ISP being completed 30 days after the admission date of 07/28/22. 2. Resident?s #3 uniform assessment instrument (UAI) dated 07/28/22 documents mechanical and human help needs for transferring. The ISP dated 09/28/22 does not include documentation of the mechanical supports needed for transferring. 3. Resident?s #2 UAI dated 10/27/22 documents mechanical and human help needs for transferring. The ISP dated 10/27/22 does not include documentation of the mechanical supports needed for transferring. 4. Resident?s #4 UAI dated 01/17/23 documents mechanical and human help needs for stairclimbing. The ISP dated 01/17/23 does not include documentation of the mechanical and human help supports needed for stairclimbing. 5. Resident?s #5 record contains a Do Not Resuscitate Order (DNR) dated 08/18/22. The DNR order was not included in the resident?s ISP dated 12/12/2022.
Plan of Correction:	What Has Been Done to Correct? Resident #3?s UAI and ISP now match showing that this resident requires both Human and Mechanical Help for stairclimbing. Resident #2?s UAI and ISP now match showing that this resident requires both Human and Mechanical Help. Resident #5?s record now reflects a DNR order on resident?s ISP. How Will Recurrence Be Prevented? The Resident Care Director and Assistant Resident Care Director were retrained on the importance of completing ISPs in a manner consistent with the regulation and individual resident?s needs on 4/5/2023 by Executive Director. The Resident Care Director and Assistant Resident Care Director attended a virtual UAI/ISP training on 4/6/2023 which included training on the importance of accurate UAI and ISP documentation. The Resident Care Director and Assistant Resident Care Director will audit current and new resident ISPs and UAIs to verify accuracy to resident needs; completing this by 6/10/2023. For the next 60 days, the Executive Director/designee will complete regular, random audits of recently completed ISPs to assure they match the UAI and current resident needs. Person Responsible: Resident Care Director/Assistant Resident Care Director/Executive Director
Standard #:	22VAC40-73-680-D
Description:	Based on the record review the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. The record for resident #9 contains a physician order dated 03/01/2023 for Novolog FlexPen 100 Unit/ML subcutaneous pen-injection including the following directions: ?blood sugars 150-200=4 units, 200-250=6 units, 250-300=8 units, greater than 300=14 units.? The resident?s medication administration record (MAR) documents on the following dates the resident was not administered Novolog according to the physician order (blood sugar greater than 300 =14 units), on the dates and times listed the MAR documents the resident was administered 10 units of Novolog for blood sugar levels greater than 300: 03/01/2023 @ 8:00 pm 03/03/2023 @ 12:00pm & 5:00pm 03/04/2023-03/06/2023 @ 5:00pm 03/06/2023-03/08/2023@ 8:00pm 03/10/2023-03/12/2023 @ 8:00pm 03/15/2023 @ 8:00pm 03/20/2023-03/22/2023 @ 8:00pm 03/24/2023-03/26/2023 @ 8:00pm 03/29/2023@ 8:00pm.
Plan of Correction:	What Has Been Done to Correct? Resident #9 was evaluated by his PCP on 4/4/2023 and was determined to continue to need insulin injections according to the physician?s current order as written in resident?s MAR. How Will Recurrence Be Prevented? On 3/31/2023, current RMAs were retrained by the Resident Care Director specifically to the administering of insulin based on the physician?s order. Current RMAs signed an acknowledgement that they understand the current order for resident #9 and other physician?s medication orders. As of 4/6/2023, an audit of this resident?s MAR was completed showing resident is receiving insulin doses according to the physician?s order. In addition, once weekly, the Resident Care Director audits the MAR to assure that orders are being followed by RMAs. In addition, a medication audit of resident files is being completed monthly by Resident Care Director and Assistant Resident Care Director. Person Responsible: Resident Care Director/Assistant Resident Care Director/Executive Director