VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Hillsville
100 Kyle Drive
Hillsville, VA 24343
(276) 728-5333

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: Sept. 10, 2019

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

Two licensing inspectors conducted a one day unannounced renewal inspection at Commonwealth Senior Living in Hillsville, VA on 09/10/2019. The inspection started at 10:30 am and concluded at 2:05 pm. The licensing inspectors observed lunch, activities, residents, resident and staff interaction, the noon medication pass, resident and staff files, and toured the building. The facility had a total census of 58 on 09/10/2019. Required postings and the previous inspection were observed to be in place. As a result of this inspection, three violations are being cited. An exit meeting was held with the administrator of the facility and at that time the opportunity was given to find items that were not readily available in the records. A corrective action plan should be developed addressing the steps to correct the noncompliance of each standard; measures to prevent the reoccurance; and the person(s) responsible for implementing each step and/or monitoring and prevention measures. The "description of action to be taken" for each violation, along with the "date to be corrected" must be returned to this office signed and dated within 10 calendar days of receipt (09/22/2019). If you have any questions or concerns please contact your inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on observations made during a review of resident records, the facility failed to ensure that each individual shall have a physical examination by an independent physician within the 30 days preceding admission. The report shall be on file at the assisted living facility and shall contain a statement that specifies whether a resident can self-administer medication and shall address all allergies and allergic reactions for each resident. EVIDENCE: 1. Resident #1 was admitted to the facility on 07/29/2019 and has an admission physical dated 07/09/2019. Resident #1 has PCN, Sulfa, NSADS, shellfish, and Keflex listed as allergies. There were no description of allergic reactions listed for PCN, Sulfa, NSADS, or shellfish. 2. Resident #2 was admitted to the facility on 07/16/2019 and has an admission physical dated 07/11/2019. Resident #2 has Clindamycin, Penicillin, and Macrodantin listed as allergies. There were no descriptons of allergic reactions listed for Clindamycin, Penicillin, or Macrodantin. Resident #2's physical did not address the question of whether or not he/she could self-administer medication. 3. Resident #3 was admitted to the facility on 10/12/2018 and has an admission physical dated 10/09/2018. Resident #2 has PCN and Morphine listed as allergies. There were no descriptions of allergic reactions listed for PCN or Morphine. 4. Resident #5 was admitted to the facility on 07/01/2018 and has an admission physical dated 06/28/2018. Resident #5 has Amoxicillin, Liptior, Zocor, Mevacor and Zanaflex listed as allergies. There were no descriptions of allergic reactions listed for Amopxicillin, Lipitor, Zocor, Mevacor, and Zanaflex.
Plan of Correction:	Resident Care Director contacted current physician and received reactions to all allergies of resident #1, #2, #3, & #5. Addendum inserted with admission physical. Resident #2's physical received clarification on ability to self-administer medication. Resident Care Director and/or designee will ensue addendum is provided with all admission physicals to ensure reactions are captured to any known allergies.[sic]
Standard #:	22VAC40-73-320-B
Description:	Based on observations made during resident record reviews, the facility failed to ensure that each resident has a risk assessment for tuberculosis completed annually. EVIDENCE: 1. Resident #4 was admitted to the facility on 08/05/2016. Resident #4 had tuberculosis risk assessments completed on 08/05/2016, 08/02/2017, and 08/02/2019. Resident #4 did not have an annual tuberculosis risk assessment completed for August 2018.
Plan of Correction:	Resident Care Director audited all medical charts to ensure annual TB compliance with all other residents. Resident #4's chart had a document inserted showing annual TB was not located by DSS and PCP signed off on document to show notification. Resident Care Director and/or designee will perform quarterly audits to ensure annual TB's are present in the medical chart for all residents. [sic]
Standard #:	22VAC40-73-980-A
Description:	Based on a tour of the building, the facility failed to have a complete first aid kit on the Assisted Living side of the building and on the Memory Care Unit. EVIDENCE: 1. The first aid kit on the Assisted Living side of the building and the first aid kit on the Memory Care Unit did not contain a flashlight, extra batteries for the flashlight, and a pair of tweezers.
Plan of Correction:	Executive Director placed a flashlight, extra batteries and pair of tweezers on both first aid kits. Executive Director and/or designee will perform monthly maintenance checks to ensure compliance with first aid kits. [sic]