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: Sept. 25, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 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 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 SANCTIONS.

Comments:

The LI for Commonwealth Senior Living at South Boston conducted an unannounced renewal study at the facility on 9/25/19 from 10am unitl 3:30pm and noted 654 resident to be in care. Resident and staff records as well as other forms of facility documentation were reviewed and interviews were conducted with resident sand staff. A tour of the physical plant was conducted and the mid day medication pass and mid day meals were observed, Please respond back with your 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 #:	22VAC40-73-1090-A
Description:	Based on a review of resident records, thew facility failed to ensure that assessment of serious cognitive impairment were completed as required. EVIDENCE: 1. The assessment of serious cognitive impairment form completed on 7/5/19 for resident 2, who is currently residing in the facility safe, secure unit has documentation that the resident is able to recognize danger and protect their own safety and welfare, which would indicate that the residents placement in a safe secure unit is inappropriate.
Plan of Correction:	Prescriber completed a new Serious Cognitive Impairment Assessment for Resident #2. Resident Care Director re-educated regarding the documentation necessary for placement in Memory Care neighborhood. Documentation for all other residents in the Memory Care neighborhood was checked to ensure compliance. Executive Director, Resident Care Director, or designee will ensure a Serious Cognitive Impairment Assessment is completed before a resident is placed in the Memory Care neighborhood. Executive Director or designee will complete random monthly audit of a minimum of 5 resident charts to ensure ongoing compliance.
Standard #:	22VAC40-73-50-B
Description:	Base on resident record reviews, the facility failed to retain acknowledgment of a disclosure statement. EVIDENCE: 1. The record for resident 1, admitted on 6/30/19 did not contain acknowledgment of the resident or their legal representative receiving a disclosure statement prior to the residents admission.
Plan of Correction:	Resident #1 disclosure statement receipt was placed in the residents file. The files for all other residents were checked to ensure compliance. Business Office Manager or designee will check the resident file at time of admission to ensure compliance. Executive Director or designee will review a minimum of 5 resident files per month to ensure ongoing compliance.
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records, the facility failed to ensure that all staff received a screening for tuberculosis annually. EVIDENCE: 1. The record for staff person 2, hired on 8/9/16, has documentation that the last screening for tuberculosis was completed on 6/5/18.
Plan of Correction:	Employee did have an annual screening as per DSS Standards but the medical provider inadvertently missed documenting the required information on the TB screening form. The employee was re-screened and all portions of the form was completed. Audit completed to ensure that all current employee TB screening documents were completely filled out. Business Office Manager will review all TB screening forms at time of submission to ensure documentation is completed appropriately. ED, RCD, or designed to complete random monthly audit of associate TB screening forms to ensure ongoing compliance.
Standard #:	22VAC40-73-310-B
Description:	Base on a review of resident records, the facility failed to ensure that a documented interview between the resident and administrator or a designee was completed prior to admission. EVIDENCE: 1. The record for resident 1, admitted 6/30/19 and resident 2, admitted 7/5/19 did not contain documentation of an interview conducted prior to the residents admissions to thew facility.
Plan of Correction:	Resident # 1 and 2 pre-admission information was documented. All other resident records were checked to make sure the pre-admission interview was documented. Executive Director, Resident Care Director, or designee will ensure all pre-admission information is obtained and documented prior to admission. Executive Director or designee audit a minimum of 5 resident files per month to ensure ongoing compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record reviews, the facility failed to ensure that identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The comprehensive ISP dated 8/11/19 for resident 1 has that the resident is on a special diet but the ISP does not identify what the special diet is. Also the history and physical dated 6/27/19 has that the resident is allergic to Sulfa, eggs, NSAIDS, Prednisone and tomatoes. The ISP has that the resident is allergic to Cipro and Lisinopril. The uniform assessment instrument (UAI) dated 8/20/19 for resident 1 has that the resident requires assistance with dressing and toileting. Staff person 1 and 4 confirm that these ADL needs are correct. The ISP for residnet 1 does not address these identified needs. 2. The history and physical dated 6/25/19 in the record for resident 2 has documentation that the resident has a Do Not Resuscitate order. The comprehensive ISP dated 8/5/19 has documentation that the resident is a Full code. The UAI dated 8/2/19 for resident 2 has that teh resdient requires supervision with feeding and is on a modified diet. The ISP does not address resident 2's diet or eating supervision.
Plan of Correction:	Resident #1 ISP was updated with the diet ordered, allergies and current assessed needs. Resident #2 ISP was updated with the diet ordered, code status, and current assessed needs. The Resident Care Director or designee will ensure that each ISP is reviewed and updated annually or if there is a change in the resident condition. The ISPs of other residents were reviewed to ensure compliance. Records reviewed to include identified need and what type of assistance staff are to provide to include coordinated services, basic needs identified, and signature of legal representative. Community will continue to complete Preliminary ISP and Comprehensive ISP in conjunction with resident, family, and/or caregivers while using the History and Physical, physician orders, UAI, and other support to ensure the individualized basic needs of the resident are adequately identified to include type of assistance needed to protect the resident?s health, safety, type of assistance required by coordinated services if applicable, and required signatures. Executive Director will review the Preliminary ISP on the date of admission. Executive Director will complete random monthly audit of a minimum of 5 Comprehensive ISPs to ensure ongoing compliance.
Standard #:	22VAC40-73-450-D
Description:	Based on a review of resident records, the facility failed to ensure that services provided by both the facility and hospice provider are included on the individualized service plan (ISP). Evidence: 1. Resident 6 is receiving hospice services which includes wound care services by Hospice. The ISP dated 8/23/19 does not specify what services are provided by the facility, as opposed to those provided by the hospice provider.
Plan of Correction:	Resident #6 ISP was updated to reflect the services provided by Hospice. The Resident Care Director or designee will ensure that each ISP is reviewed and updated annually or if there is a change in the resident condition. The ISPs of other residents were reviewed to ensure compliance. Records reviewed to include identified need and what type of assistance staff are to provide to include coordinated services, basic needs identified, and signature of legal representative. Community will continue to complete Preliminary ISP and Comprehensive ISP in conjunction with resident, family, and/or caregivers while using the History and Physical, physician orders, UAI, and other support to ensure the individualized basic needs of the resident are adequately identified to include type of assistance needed to protect the resident?s health, safety, type of assistance required by coordinated services if applicable, and required signatures. Executive Director will review the Preliminary ISP on the date of admission. Executive Director will complete random monthly audit of a minimum of 5 Comprehensive ISPs to ensure ongoing compliance
Standard #:	22VAC40-73-610-B
Description:	Based on observations of the facility physical plant, the fcility failed to post post menus for the current week in an area conspicuous to residents. EVIDENCE: 1. The facility menus for the current week were not posted on the AL side or the memory care unit on the day of inspection. It was noted that only a daily menu was posted on the AL side.
Plan of Correction:	Weekly menu was posted. Dining Service Director was re-educated on the posting of the weekly menu. Dining Services Director or designee will ensure that the menus for meals and snacks are posted for the current week in an area conspicuous to residents. Executive Director or designee will round a minimum of 2 times per day to ensure continued compliance.
Standard #:	22VAC40-73-660-A
Description:	Based on observations of the facility physical plant, the facility failed to ensure that areas where medications were stored were locked. EVIDENCE: 1. A pharmacy tote box containing bubble packed medications for residents 2, 5, 9 and 10 was noted in an unlocked closet next to the beauty salon.
Plan of Correction:	Medications were moved to a locked area. A lock was added to this closet for future secure storage. All nurses and RMAs were re-educated on the safety and security of medications and key control to ensure resident safety and compliance with DSS Standards. Executive Director, Resident Care Director, or designee will complete random checks to ensure continued compliance.
Standard #:	22VAC40-73-860-I
Description:	Based on observations of the facility physical plant, the facility failed to store cleaning supplies in a locked area. EVIDENCE: 1. A bottle of Zep Odor Control Concentrate was located under the hand washing sink by the nurses station in the memory care unit.
Plan of Correction:	All housekeeping chemicals were secured in a locked cabinet. The area under the sink is secured prohibiting accessibility to be used as a storage area. Housekeeping Associates were re-educated on the requirement to store cleaning supplies and other hazardous materials in a locked cabinet. Maintenance Director will continue to round in the community daily, Executive Director will round in the community a minimum of 2 times per day and Program director will round in the memory care neighborhood a multiple times throughout the day to ensure continued compliance,.