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: Oct. 16, 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

Technical Assistance:

As a best practice, have residents demonstrate to your staff that they are able to care for their own urostomy and colonostomy devices on a routine basis.

Comments:

Two license inspectors conducted an unannounced mandated license renewal inspection at Commonwealth Senior Living in Radford, on 10/16/2019. The inspection began at 10:55 am and concluded at 2:05 pm. A tour of the building and grounds was conducted. Residents and collaterals were interviewed. Resident and staff interactions were observed. The noon meal and noon medication pass were observed. Resident and staff files were reviewed. Medications and Medication Administration Records were observed. The facility was found to have 50 residents in care the day of the inspection. Required postings and the previous inspection were observed to be in place. An exit meeting was conducted with the administrator and other staff on 10/16/2019 and at that time the opportunity was given to find items that were not readily available in the records. As a result of this inspection one violation is being cited. A corrective action plan should be developed addressing steps to correct the noncompliance of each standard; measures to prevent the occurrence; and 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 sign and dated within 10 calendar days (11/04/2019) of receipt. If you have any questions please contact your inspector at 276-608-1067. Thank you or your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on observations made during the medication cart audit, the facility failed to follow their medication plan to have a plan for proper disposal of medication. EVIDENCE: 1. Resident # 11 was prescribed Esomeprazole MAG 40 mg capsules take 1 capsule one time daily as needed for reflux and this medication was on the medication cart but was not listed on the MAR. The licensing inspector located a discontinue order for this medication dated 07/19/2019.
Plan of Correction:	Expired medication was immediately removed from the cart by Resident Care Director. Resident care Director re-educated nurses and Registered Medication Aides on the medication management policy and procedure. Complete Cart audits were completed and reviewed for accuracy according to physician orders and expiration dates. [sic]