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: May 4, 2023

Complaint Related: Yes

Areas Reviewed:

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-80 COMPLAINT INVESTIGATION

Technical Assistance:

Documentation and notifications when a medication error occurs.

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 05/04/2023 from 9:33 am to 2:45 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on (04/14/2023) regarding allegations in the area(s) of: Staffing and Supervision and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 2 Observations by licensing inspector: An activity was observed in the safe, secure unit. The call bell system was monitored. A review of the staffing schedule was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the (complaint(s)/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 #:	22VAC40-73-640-A
Complaint related:	No
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. Evidence: 1. During the medication cart observation with staff #1 the following expired medications were observed on the medication cart located in the assisted living unit: Albuterol, expired 04/30/23; Atropine SOL, expired 02/2023; Lidocaine Ointment, expired 01/2023; Lorazepam, expired 02/05/23; 10 packs of Morphine SOL Syringes, expired 03/26/23 and 03/27/23. 2. During the medication cart observation with staff #4 the following expired medication was observed on the medication cart located in the safe, secure unit: Nitrogylcerin Tablets, expired 05/27/22. 3. The medication cart located on the assisted living unit contained 9 unopened packs and 1 opened pack of Morphine SOL 10/0.5ml syringes for resident #11. The 10 packs of morphine were labeled with expiration dates for 03/26/23 and 03/27/23. The resident?s medication administration record (MAR) and controlled substance count sheet for April 2023 documents the resident was administered Morphine SOL 10/0.5ml on 04/09/2023, which was after the medication?s expiration date.
Plan of Correction:	Expired medication found by the LI during the medication cart audits were properly disposed of according to the medication management plan. Audit of both med carts was completed to assure medications on cart are current and in date. Current and new RMAs will receive training to the community?s medication management plan as it pertains to outdated medications. This training was completed on 5/16/2023. Further training to the medication plan will be ongoing until 7/25/2023. For the next 60 days, the Resident Care Director will audit the med cart in Assisted Living weekly and the ARCD will audit the medication cart weekly in Memory Care for outdated medications; audits will be provided to Executive Director, upon completion, for review. Person Responsible: Resident Care Director/Assistant Resident Care Director
Standard #:	22VAC40-73-680-D
Complaint related:	No
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 (BG) 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 and times the resident was not administered Novolog according to the physician order: 4/04/23 @ 8:00 am, BG (283) administered 0 units 4/06/23 @ 8:00pm, BG (348) administered 10 units 4/07/23 @ 8:00 pm, BG (403) administered 10 units 4/09/23 @ 8:00 pm, BG (348) administered10 units 4/11/23 @5:00pm, no record of BG check 4/13/23 @ 8:00pm, BG (246) administered 8 units 4/17/23 @ 8:00 am, BG (381) administered 18 units 4/18/23@ 8:00 pm, BG (417) administered 10 units 4/21/23 @ 8:00 pm, BG (497) administered 10 units 4/23/23 @ 8:00 pm, BG (381) administered 12 units 4/26/23 @ 8:00pm, BG (343) administered 10 units 4/28/23 @ 12:00pm, BG (319) administered 8 units 4/30/23 @ 8:00pm, BG (239) administered 8 units 5/03/23 @ 8:00pm, BG (342) administered 10 units
Plan of Correction:	Resident #9?s sliding scale insulin order has been changed by physician with the following directions: ?blood sugars (BG) Novolog SQ 150-199-4 units, 200-249-6 units, 250-299-8 units, 300 or greater-14 units?. In addition, RMAs were given instructions and expectations regarding the new unit dosing on 5/5/2023. Resident?s PCP was notified of medication error. PCP gave no new orders or directions regarding medication error. On 5/16/2023, training was provided to medication staff on Resident #9?s order. Further training to Diabetes Management ? Insulin Management will be completed by Southern Pharmacy before or on 6/15/2023. For the next 60 days, the Resident Care Director or designee will complete regular, random reviews of MARs to assure medications are being administered as per regulatory standards. Person Responsible: Resident Care Director/designee