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: July 20, 2023

Complaint Related: Yes

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 22VAC40-80 COMPLAINT INVESTIGATION

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 07/20/23 from 8:40 am to 3:00 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 07/06/2023 and 07/11/2023 regarding allegations in the area(s) of: Resident Care and Related Services and The Safe Secure Unit 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: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of the safe secure unit, and assisted living unit was completed, and a review of the medication cart. Lunch and an activity were observed. 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 allegation?s 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 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 #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on the record review and staff interview the facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed prior to admission. 1. The record for resident #2, admission date of 06/08/23, did not contain a UAI. 2. Staff # 4, acknowledged the record for resident #2 did not contain a UAI and evidence of completion of a UAI was not provided.
Plan of Correction:	Audit will be completed of current residents for UAI completion. UAIs will be completed prior to admission and reviewed by ED/designee. For the next 60 days, the ED/designer will complete an audit of new admissions to assure UAI is completed prior to admission. Resident Care Director/ Designee
Standard #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	Based on the record review and staff interview, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects the health, safety and welfare. A preliminary plan of care (PPC) is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission. Evidence: 1. The record for resident #2, admission date of 06/08/23, did not contain a PPC or an ISP completed on or within seven days prior to the resident?s admission. 2. Staff # 2, acknowledged the record for resident #2 did not contain a PPC or an ISP and evidence of completion of a PPC or an ISP was not provided.
Plan of Correction:	Current resident charts will be audited for Preliminary Plan of Care Preliminary Plan of Care will be developed within 7 days prior to or on day of admission and given to Executive Director/ Designee for review. Over the next 60 days, the ED/designee will complete an audit of new admissions to assure Preliminary Plan of Care is signed and available in chart. Executive Director/ Resident Care Director/ Designee
Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on the record review the facility failed to implement a written plan for medication management to include methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. Evidence: 1. The review of the facility?s ?Shift Change Controlled Substance Count Check? located in the assisted living unit did not contain documentation of ?the off going and on-coming med aides? both signing the controlled substance count form on the following dates and times: 7/01/23 @ 7:00am, 3:00pm 7/03/23@ 3:00pm, 11:00pm 7/19/23 @ 7:00am, 3:00pm, 11:00pm 7/19/23 @ 3:00pm
Plan of Correction:	Registered Medication Aides/ Nurses have been in serviced on proper management of controlled substances to include completion of shift-to-shift count.. Over the next 60 days, the RCD/designee will complete review of Controlled Substances Shift to Shift log for signatures. The ED/designer will complete weekly reviews for 30 days to assure continued compliance. Resident Care Director/ Designee
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
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 #1 contains a physician order dated 03/06/2023 for Humalog: ?check FSBS (Finger stick blood sugar) three times a day and inject SSI:151-200 =2U, 201-250=4U, 251-300=6U, 301-350=8U, 351-400=10U The resident?s medication administration record (MAR) documents on the following dates and times the resident was not administered Humalog according to the physician order: 07/10/23, BS (Blood Sugar) =367, given 8 units; 07/11/23, BS =195, given 5 units; No record of FSBS checks on 07/12/23 and 07/14/23 @ 8:30pm.
Plan of Correction:	Training has been completed with current medication staff on competing medication pass per MD orders. Over the next 60 days, the RCD/designee will complete a regular review of current resident MARs to assure meds are being administered per MD order. Concerns will e addressed with med staff. The ED/designee will complete a random review of current resident MARs, for the next 30 days, to assure physician orders are being followed in accordance with regulatory standards. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee