VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Radford
7486 Lee Highway
Radford, VA 24141
(540) 639-2411

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: Sept. 6, 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

Technical Assistance:

Please ensure that each and every page of the new disclosure form is being initialed at the bottom by the resident or the responsible party of the resident.

Comments:

Two licensing inspectors conducted an unannounced monitoring inspection at Commonwealth Senior Living in Radford on 09/06/2019. The inspection began at 9:45 am and concluded at 1:15 pm. Resident and staff files, the building, and resident rooms were reviewed and the noon medication pass and lunch were observed. Medication Administration Records, medications, and physician's orders were reviewed. As a result of this inspection four violations are being cited. An exit meeting was conducted with the administrator and other key staff of the facility on 09/06/2019 and at that time the opportunity was given to find items that could not be located in the files. Please provide a plan of correction and date to be corrected for each violation cited and return a signed and dated copy of the violation notice back to your licensing inspector within 10 calendar days (09/21/2019) of receipt. 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 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 of such examination shall be on file at the assisted living facility and shall contain a statement that specifies whether the individual is or is not capable of self administering medication. EVIDENCE: 1. Resident # 1 was admitted to the facility on 08/13/2019. Resident # 1 had an admission physical dated 08/12/2019 and the question of whether or not the individual was capable of self administering medication was left blank. 2. Resident #2 was admitted to the facility on 08/15/2019. Resident #2 had an admission physical dated 07/18/2013. The general physical condition was left blank.
Plan of Correction:	Resident Care Director re-educated and provided correction to associates who complete resident admissions documentation. Resident #1 and Resident #2 admission documentation were corrected with a clarification order and addendum signed by the physician. All admissions and History and Physicals prior to admission will be audit by the Resident Care Director and/or Designee for completeness. [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on observations made during an audit of the medication carts, the facility failed to follow their current medication management plan to prevent the use of outdated, damaged or contaminated medications EVIDENCE: 1. Both Medication cart AD and B had loose pills in the bottom of the drawer containing resident medications in bubble packs. 2. Resident #5/s Gabapentin 100 mg was discontinued on 08/07/2019, but as of 09/06/2019, the medication was still available in the medication cart and available for administration on 09/06/2019. Both of these medication were discontinued on 08/17/2019 upon Resident #5s return from the hospital.
Plan of Correction:	Executive Director and Resident Care Director re-educated Registered Medication Aides on the medication management policy and procedure. Complete Cart audits were completed and reviewed for accuracy according to physician orders. Resident Care Director to work with Southern Pharmacy partner for packaging issues with bingo cards and will address concerns for storage as necessary. Resident Care Director and or designee will complete medication cart audits minimum of twice monthly to ensure compliance. [sic]
Standard #:	22VAC40-73-860-I
Description:	Based on observations made during the morning tour of the building, the facility failed to store all cleaning supplies and other hazardous materials in a locked area. EVIDENCE: 1. The licensing inspector observed the laundry room door located on the back hallway of the Assisted Living side of the facility to be unlocked and accessible to residents. There was a bottle of Husky Extraction Carpet Concentrate on the top shelf above the washing machines that contained a label caution keep out of reach of children.
Plan of Correction:	Inservice was completed on proper storage of hazardous materials by Resident Care Director. Laundry room will remain locked and all chemicals will be storage properly and properly labeled. [sic]
Standard #:	22VAC40-73-870-A
Description:	Based on the morning tour of the building, the facility failed to ensure all exterior areas of the building are maintained and in good repair. EVIDENCE: 1. The outside common area on the assisted living side of the building contained a side walk with a portion of the side walk busted and broken leaving protruding stone one inch above the base of the sidewalk creating a trip hazard for residents. 2. Staff #1 stated this has been reported to the corporate office and an estimate had been completed to repair the side walk.
Plan of Correction:	Executive Director had prior identified need for sidewalk in AL courtyard to be repaired and received estimate. Sidewalks were repaired and completed on 09/12/2019 [sic]