VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at South Boston
435 Hamilton Boulevard
South boston, VA 24592
(434) 575-5400

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: June 26, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS

Comments:

The Piedmont Licensing Office received an anonymous complaint in regards to Commonwealth Senior Living at South Boston. The complaint alleges that on the safe secure unit a male resident entered a female residents room and that the residents were not assessed for injuries. The LI for Commonwealth Senior Living at South Boston conducted an unannounced complaint investigation at the facility on 6/26/19 from 12:00pm until 2:00pm in conjunction with another LI. A tour of the facility physical plant was conducted and interviews were conducted with staff. Resident records as well as other forms of facility documentation were reviewed. Based on the preponderance of all evidence available for review this complaint is founded. Please respond back with a plan of correction within 10 days of receipt of this notice. If you have any questions please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-300-B
Complaint related:	Yes
Description:	Based on resident record and facility documentation review and interviews with staff, the facility failed to ensure that information of significant happenings or problems experienced by residents was included in the records of the involved residents. EVIDENCE: 1. The facility med aide to med aide communications log on the memory care unit for 6/14/19 has documentation that resident 1's bed was broken by resident 2. The facility camera indicates that resident 2 entered resident 1's room at 9:16pm on 6/14/19. Facility staff are seen entering resident 1's room at 9:24pm on 6/14/19 and then remove resident 2 from the room. Staff interviews indicate that upon entering the room resident 1 was sitting up in a recliner chair and resident 2 was lying in the bed with one side of the bed collapsed. Staff expressed that resident 1 began asking what they were doing and to leave resident 2 alone because he was sleeping. The records for residents 1 and 2 did not contain any information of this significant happening to include assessment of the residents for any injuries or measures put in place for monitoring to ensure that resident 2 did not re-enter resident 1's room.
Plan of Correction:	All care associates to include (nurses, RMAs, and Resident Care Associates) were re-educated of community policy of documenting events of exception on the End of Shift Report. The Resident Care Director or designee will determine what situations require incident reporting, follow up, medical interventions, and assessments. Review of documentation policy will take place during monthly staff meetings. The end of shift report and med aide to med aide report will be reviewed daily by the Resident Care Director or designee to ensure that all incidents regarding the care, health, safety and well-being of residents are being addressed to ensure on-going compliance.