VIRGINIA DEPARTMENT OF SOCIAL SERVICES

COMMONWEALTH SENIOR LlVING AT CHURCHLAND HOUSE
4916 West Norfolk Road
Portsmouth, VA 23703
(757) 483-1780

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Jan. 31, 2022 and Feb. 4, 2022

Complaint Related: No

Areas Reviewed:

Part I- General Provisions Part II- Administration and Administrative Services Part III- Personnel Part IV- Staffing and Supervision Part V- Admission, Retention and Discharge of Residents Part VI- Resident Care and Resident Services Part VII- Resident Accommodations and Related Provisions Part VIII- Buildings and Grounds Part IX- Emergency Preparedness Part X- Additional Requirements for facilities that care for adults with serious cognitive impairments Background Checks for Assisted Living Facilities The Sworn Statement or Affirmation The Criminal History Record Report Protection of adults and reporting

Technical Assistance:

Technical assistance: physician's order need to specify area for cream to be applied; powder cream should specify the amount of powder to be administered; bedroom spacing when more than one resident reside in room; healthcare oversight audit should be conducted by someone not completing UAI/ISPs; equipment need by resident should be available (example- nebulizer)

Comments:

An unannounced renewal inspection was conducted on 1-31-22 (ar 08:00/ dep 18:00). Facility census was 44. Medication pass observed, tour of facility, breakfast meal observed, activity observed; emergency preparedness reviewed, staff and resident records reviewed, first aid kit reviewed, resident council minutes reviewed. Violations and technical assistance provided throughout the day during the inspection. An exit conducted with administrator and staff on 1-31-22. A final exit conducted with administrator via telephone on 2-4-22.The acknowledgement form was completed and sent to the administrator. Please complete the 'Plan of Correction' and 'Date to be Corrected' for each violation cited on the violation notice and return it to me within 10 calendar days from today ,2-9-22. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible.

Violations:

Standard #:	22VAC40-73-310-H
Description:	Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions or care need for four of five sampled resident?s record Evidence: 1. Resident 1?s January 2022 medication administration record (mar) documented resident prescribed Seroquel. Resident?s record did not include a treatment plan for psychotropic medication. 2. Resident #2?s January 2022 MAR documented resident prescribed Escitalopram and Lorazepam. Resident?s record did not include a signed treatment plan for psychotropic medication. 3. Resident #3?s January 2022 Mar documented resident prescribed Alprazolam, Mirtazapine and Venlafaxine. Resident?s record did not include a signed treatment plan for psychotropic medication. 4. Resident #4?s January 2022 Mar documented resident prescribed Risperidone. Resident?s record did not include a psychotropic treatment plan. 5. On 1-31-22 and 2-3-22 during exit meeting, staff #1 and 2 acknowledged psychotropic treatment plans were not available for residents #1, #2, #3 and #4.
Plan of Correction:	Resident #1,2,3,and 4?s psychotropic treatment plans were put in place. The Resident Care director or designee will ensure that the physician puts a treatment plan in place for each psychotropic medication ordered. A monthly audit will be conducted by the Resident Care Director or Designee for all psychotropic medications to ensure that there are plans in place and current according to physician orders. Resident Care Director or designee 2-11-22 and on-going
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the resident?s individualized service plan (ISP) included all assessed needs for four of five records reviewed. Evidence: 1. Resident #1?s uniformed assessment instrument (UAI) dated 1-7-22 documented resident needed assistance with bowel, (less than weekly) and bladder (greater than weekly). The individualized service plan (ISP) dated 1-17-22 did not document who, when and what services would be provided. Resident?s ISP documented resident to not receive cardiopulmonary resuscitation (CPR). The record did not contain documentation of a DNR document signed by a prescriber. 2. Resident #2?s UAI dated 12-31-21 documented abusive/aggressive/disruptive behavior. The ISP documented services to be provided as ?may require special tolerance or staff training?. Resident?s Preliminary ISP dated 11-5-21 and comprehensive ISP dated 1-7-22 did not include resident?s physical therapy services. Physical therapy evaluation documented 11-17-21 and discontinued 12-21-21. 3. Resident #3?s ISP dated 11-26-21 did not document resident?s physical therapy services documented on 8-25-21, 9-10-21 and 9-17-21; physician?s order dated 7-21-21. 4. Resident #4?s ISP dated 11-2-21 did not include resident?s physical therapy services 7-8-21 and discontinued 9-14-21 and services documented with another agency 12-3-21, 12-6-21 and 12-13-21. When inquired if physical therapy services are currently being provided or discontinued, staff #2 did not know. Record documented occupational therapy evaluation on 8-11-21 and services discontinued 9-1-21. Skilled nursing services for incision to right knee services and discontinued 7-14-21 was not documented on resident?s ISP. 5. On 1-31-22 and 2-3-22 during exit meeting, staff #1 and #2 acknowledged residents #1, #2, #3 and #4?s ISP did not include all accessed needs.
Plan of Correction:	The ISP record for resident #1, 2, 3, and 4 were reviewed and updated accordingly. The community will address needs of residents during the weekly meeting and will updated ISP to reflect those needs and or changes. Resident Care Director or designee 2-22-22 and on-going
Standard #:	22VAC40-73-450-D
Description:	Based on record review, the facility failed to ensure when hospice care is provided to a resident, the services provided by each shall be included on the individualized service plan (ISP) for one of five sampled records. Evidence: 1. Resident #2?s record documented hospice services dated 11-5-21. The services documented in the contracted agreement noted skilled nursing, social worker, chaplain and a caregiver/aide. The ISP dated 11-5-21 and 1-17-22 did not include when, what and where these services were to be provided. 2. On 1-31-22 and 2-3-22 during the exit meeting staff #1 and #2 acknowledged the ISP did not include the specific hospice services being provided for resident #2.
Plan of Correction:	The ISP record for resident #2 was reviewed and updated accordingly to reflect all services being rendered. The community will address needs of residents during the weekly meeting and updated the ISP to reflect those needs and or changes. Resident Care Director or designee 2-11-22 and on-going
Standard #:	22VAC40-73-470-A
Description:	Based on record review and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of a resident was met for one of five sampled records. Evidence: 1. Resident #3?s record included a signed physician?s order dated 7-21-21 for physical therapy, occupational therapy and speech therapy. The resident?s record did not document occupational therapy and speech therapy services evaluated and/or completed. The ISP dated 11-16-21 did not document services beginning and/or ending date. 2. On 1-31-22 and 2-3-22, the physician?s order for speech and occupational therapy evaluation and treatment not being completed was addressed with staff #1 and #2.
Plan of Correction:	The record for resident #3 was reviewed. The resident was opened to hospice services on 2-3-22 and the MD wrote new orders to include physical therapy but not speech or occupational therapy. Since the physician changed the orders the speech and occupational therapy was not completed. The doctors most current orders will always be followed. The community will ask for a discontinued order if needed. Resident Care Director or designee 2-9-22 and on-going
Standard #:	22VAC40-73-640-A
Description:	Based on record review, observation and staff interviewed, the facility failed to comply with its medication management plan to ensure resident?s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: 1. On 1-31-22 during the medication pass observation with staff #5, resident #1?s Gabapentin was not available for the 9:00 a.m. administration. Resident #3?s Diclofenac cream was not available for the 9:00 a.m. administration. 2. On 1-31-22, resident #5?s hospice medication, Bisacodyl suppositories and Acetaminophen dated 11-14-20 were in the refrigerator on the safe, secure unit. According to staff #3, resident #5?s hospice services were discontinued November 2021. Staff #3 acknowledged the medication should not be in the refrigerator. 3. On 1-31-22 and 2-4-22 during the exit meeting, staff #1 and #2 acknowledged resident?s medication should be present and available at time of administration.
Plan of Correction:	The medication for resident #1 and #3 was ordered prior to it not being available per medication management plan, the medication arrived to the community 1-31-22. The community contacted the pharmacy and reminded them that if they cannot provide medication refills timely that they needed to follow the plan and use the backup pharmacy to ensure that medications are on hand regardless of the inclement weather. The staff will reorder medications per the policy. The pharmacy will receive a call if a medication ordered does not come in timely so that it can be sent through the backup pharmacy. A medication cart audit will continued to be done to ensure that all medications are available. Resident Care Director or designee 2-9-22 and on-going
Standard #:	22VAC40-73-680-M
Description:	Based on record review, observation and staff interviewed, the facility failed to ensure medications ordered for PRN administration shall be available, properly labeled for this specific resident, and properly stored at the facility. Evidence: 1. On 1-31-22 during medication pass observation with staff #6, resident #4?s Loperamide was not available. 2. A check of the medication cart on the safe, secure unit (Sweet Memories) with staff # 3 and #7, resident #5?s Tylenol was not available. 3. On 1-31-22 and 2-4-22, staff #1 acknowledged resident?s PRN medications should be available in the facility.
Plan of Correction:	The medication for resident #4 and #5 was ordered prior to it not being available per medication management plan, the medication arrived to the community 1-31-22. The community contacted the pharmacy and reminded them that if they cannot provide medication refills timely that they needed to follow the plan and use the backup pharmacy to ensure that medications are on hand regardless of the inclement weather. The staff will reorder medications per the policy. The pharmacy will receive a call if a medication ordered does not come in timely so that it can be sent through the backup pharmacy. A medication cart audit will continued to be done to ensure that all medications are available. Resident Care Director or designee 2-9-22 and on-going
Standard #:	22VAC40-73-700-2
Description:	Based on record review, observation and staff interview, the facility failed to ensure when oxygen therapy is provided, the facility shall ensure it post ?NO Smoking ?Oxygen In Use? signs in the room of a building where oxygen is in use. Evidence: 1. On 1-31-22 during medication pass with staff #5, upon entering resident #2?s room, an oxygen tank was present and plugged into the wall outlet. There was no Oxygen sign present in the room and no sign was posted outside the resident?s room. Resident #2?s record included a physician?s order for oxygen dated 1-26-22. 2. On 1-31-22 and 2-4-22 during the exit meeting, staff #1 and #2 acknowledged the oxygen sign should have been posted.
Plan of Correction:	The staff immediately placed an oxygen on use sign on the outside of the door to resident #2. The community will ensure that when oxygen is delivered for a resident it will be checked in with the resident care director or designee before placing it into the room of the resident. The resident care director or designee will provide an oxygen in use sign to each resident that has oxygen and it will be placed on the outside of the door visible to others. 2-11-22 and on-going
Standard #:	22VAC40-73-860-G
Description:	Based on observation and staff interviewed, the facility failed to ensure the hot water at taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F). Evidence: 1. On 1-31-22 during a tour of the facility with staff #1, #3 and #4, the water temperature in room #130 on the safe, secure unit (Sweet Memories) was 124 degrees F. 2. On 1-31-22 and 2-4-22, staff #1 acknowledged the water temperature was beyond the required degrees.
Plan of Correction:	The maintenance director adjusted the water heater immediately to get the desired temperature. The maintenance director will continue to do weekly water temperature checks in random resident rooms and will continue to document them in the designated binder. Maintenance director 2-9-22 and on-going