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: Aug. 17, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 08/17/2020 and concluded on 09/16/2020. A self-reported incident was received by the department regarding allegations in the areas of the safe and secure unit. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards of law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice. As a result of this inspection three violations are being cited. Please develop a plan of correction for each violation cited along with a date of correction and return a signed and dated copy back to the licensing office within 10 calendar days (09/26/2020) or receipt. If you have any questions please feel free to contact your licensing inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-1150-B
Description:	Based on staff interview, documentation, and picture documentation, the facility failed to ensure that there were protective devices on the bedroom windows of residents to prevent the windows from being opened wide enough for a resident to crawl though. EVIDENCE: 1. Staff #1 stated there were rubber stoppers on all windows in memory care prior to this incident. Now, as seen in pictures sent to the Licensing Inspector, the facility has replaced all rubber stoppers with more sturdy, metal stoppers, which should prevent the opening of the window large enough for a resident to crawl through. 2. On 08/10/2020 Resident #1 was able to open his window and push it beyond the rubber stoppers allowing him to crawl through the window which led to a safe and secure courtyard area. Resident #1?s window was approximately 35.5 inches from the ground, according to Staff#1. Resident #1 suffered abrasions to his face and a skin tear to his hand, he was sent to the hospital for evaluation and returned to the community with no new medical orders.
Plan of Correction:	All rubber stoppers on windows on memory care were replaced with sturdy metal stoppers, which should prevent windows from opening large enough for a resident to crawl through. Maintenance Director will check memory care windows on daily rounds to ensure all stoppers are intact and working correctly, this will be ongoing. Executive director to check memory care windows periodically to ensure regulatory compliance. [sic]
Standard #:	22VAC40-73-310-H
Description:	Based on observations made during documentation review, and in accordance with 63.0-1805 D of the Code of Virginia the facility failed to ensure that they shall not admit or retain individuals with any of the following conditions or care needs. EVIDENCE: 1. Resident #1 was admitted to the facility on 07/28/2020. The admission physical was dated 07/24/2020. 2. The physical dated 07/24/2020 has ?yes? checked for ?a condition requiring continuous licensed nursing care? on the last page of the physical under ?Does this individual have any of the following conditions or care needs??. 3. On 08/17/2020 Staff #2 has initialed that she received verbal consent to change a condition requiring licensed nursing care to be checked ?no? per instruction of the medical professional completing the examination. 4. From admission on 07/28/2020 until 08/17/2020 when the documented change was made on, the facility assumed care for Resident #1, which had a documented prohibitive condition for 21 days.
Plan of Correction:	Resident #1's History and Physical was corrected on 08/17/2020 to reflect "No" for a condition requiring continuous nursing care under prohibitive conditions. Executive Director, Resident Care Director, and Assistant Resident care Director will review all new resident's history and physical prior to resident moving into community. If the physician has checked "yes" under prohibitive conditions, physician will be notified immediately for clarification prior to move in. An audit of all H7P's will be conducted by September 24, 2020 to assure regulatory compliance; this audit will be ongoing for all future items as well. [sic]
Standard #:	22VAC40-73-320-A
Description:	Based on documentation review, the facility failed to include all required documentation on the physical examination report 30 days prior to admission. EVIDENCE: 1. Resident #1 was admitted to the facility on 07/28/2020. The physical examination report for Resident #1 was dated 7/24/2020. Sulfa is documented as an allergy, but there are no reactions included.
Plan of Correction:	Resident #1 physician was contacted to obtain documentation for reactions to Sulfa Allergy. Resident's medical record reflects reactions to Sulfa Allergy. Executive Director, Resident Care Director, and Assistant Resident Care Director will review all new resident's history and physical prior to resident moving into community. If allergies are listed ED, RCD, ARCD and or designee will ensure a reaction to that allergy is documented on history and physical. An audit of all H7Ps will be conducted by September 25, 2020, to assure regulatory compliance; this audit will be ongoing for all future items as well. [sic]