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. 14, 2020

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 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 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

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 renewal inspection was initiated on 9/11/2020 and concluded on 9/16/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 66. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, staff schedules,Fire and Health Inspections, health care and dietitian oversights, fire drill logs etc. submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1110-A
Description:	Based on a review of resident records, the facility failed to ensure that determination from the facility administrator for placement into a safe, secure unit was written and placed in the residents records. EVIDENCE: 1. The record for resident 1 has documentation that the resident was placed in the facility safe, secure unit on 3/24/20. The record lacks documentation of written determination for appropriate placement from the facility administrator.
Plan of Correction:	Facility administrator reviewed documents, determined approval for placement into a safe, secure unit and placed written documentation in the records for Resident #1. Executive Director will audit all resident records to ensure proper documentation of written determination for appropriate placement and will review, determine, and document for all new admissions. Executive Director and Resident Care Director will be responsible.
Standard #:	22VAC40-73-200-B
Description:	Based on a review of resident and staff records and staff interviews, the facility failed to ensure that staff received training specific to the special health care needs of residents. EVIDENCE: 1. The record for resident 2 has documentation of the resident having an indwelling foley catheter, requiring foley catheter care needs. Training for foley catheter care was not documented in the training logs for staff persons 1 through 4. Per a phone interview with staff persons 5 and 6 it was expressed that foley care training has not been completed with all direct care staff.
Plan of Correction:	Foley training scheduled with attending Home Health Agency. Resident Care Director and Assistant Resident Care Director will ensure staff receive training specific to the special health care needs of residents.
Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records, the facility failed to ensure that new staff received certification in first aid within 60 days of employment . EVIDENCE: 1. The record for staff person 1, hired on 12/9/19 and staff person 4, hired on 11/18/19, did not contain documentation that these employees had received certification in first aid within 60 days of the date of their employment.
Plan of Correction:	Associate #1 and #4 completed first aid training day of inspection. Community associates will receive certification within the first 60 days of employment. The remainder of associates files were reviewed to ensure proper documentation and training. Business Office Manager and Resident Care Director will be responsible.
Standard #:	22VAC40-73-325-B
Description:	Based on a review of resident records, the facility to ensure that a fall risk rating was completed after a fall. EVIDENCE: 1. The record for resident 2 has documentation of the resident falling on 9/6/2020 but the record did not contain documentation that a fall risk rating was completed on resident 2 after this fall.
Plan of Correction:	Fall risk assessment was completed for resident #2. Resident Care Director or designee will complete fall risk rating after a resident fall. Resident Care Director and Assistant Resident Care Director will complete audits to ensure fall risk assessments are completed and documented properly. Resident Care Director or Assistant Resident Care Director will be responsible.
Standard #:	22VAC40-73-440-D
Description:	Based on a review of resident records, the facility failed to ensure that uniform assessment instruments (UAIs) were completed as required. EVIDENCE: 1. The UAI dated 6/24/20 in the record for resident 2 has documentation that the resident has bladder incontinence weekly or more. This is inconsistent with the record for resident 2 as there is documentation that the resident has an indwelling foley catheter. Per a phone interview with staff person 5 and 6, it was expressed that resident 2 does have a foley catheter.
Plan of Correction:	Resident # 2: UAI was updated to reflect the indwelling foley catheter. Resident Care Director will review completed UAI to ensure appropriate incontinence need is selected reflecting the individual need of the resident. Executive Director and Resident Care Director will review UAI to ensure ongoing compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISPs) and that dates of identified needs and goal dates were documented on ISPs. EVIDENCE: 1. The ISPs in the record for residents 1 through 4 did not contain the date needs were identified or the goal dates for all identified needs on the ISPs. 2. The ISP dated 8/26/20 in the record for resident 1 has documentation that the resident has numerous medication allergies but the ISP does not include a written description of what services will be provided to address this identified need, who will be providing the service, when and where and the expected outcome. 3. The uniform assessment instrument (UAI) dated 6/24/20 in the record for resident 2 has documentation that eh resident is incontinent on bowels. The record also has documentation of the requiring wound care services and has an indwelling foley catheter. The ISP dated 6/24/20 for resident 2 does not have documentation of the services that the facility is providing to address these identified needs. 4. The UAI dated 5/27/20 in the record for resident 3 has documentation that the resident is incontinent of bowel and bladder. The record also has documentation that the resident is on a No Added Salt Diet and requires the use of TED stockings, on daily in the morning and removed at bedtime. The ISP dated 5/27/20 for resident 3 does not have documentation of the services that the facility is providing to address these identified needs. 5. The ISP dated 8/20/20 in the record for resident 4 has documentation that the resident is on a No Concentrated Sweet diet and has numerous medication allergies but the ISP does not include a written description of what services will be provided to address this identified need, who will be providing the service, when and where and the expected outcome.
Plan of Correction:	Resident 1 through 4 ISPs were updated to contain the date needs were identified and the goal dates for all identified needs on the ISPs. Resident #1 ISP was updated to reflect medication allergies, written description of what services will be provided, when the services will be provided, where the services will be provided and the expected outcome. Resident #2: ISP was updated to reflect documented services the community provides for the resident?s bowel incontinence, wound care and indwelling foley catheter. Resident #3: ISP was updated to reflect incontinence of bowl and bladder, current diet order, use of TED hose along with hose on and daily removal. Resident #4 ISP was updated with the diet order, allergies, and current assessed needs. The ISPs of other residents were reviewed to ensure compliance. Records reviewed to include identified needs and what type of assistance staff are to provide to include coordinated services, basic needs identified, goal dates and signature of legal representative. Resident Care Director and Assistant Resident Care Director will complete random monthly audits to ensure ongoing compliance. Resident Care Director and Assistant Resident Care Director will be responsible.
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. The comprehensive ISP dated 5/27/2020 for resident 3 has documentation that the resident is receiving hospice services but the ISP does not specify/detail what services are being provided by hospice to the resident.
Plan of Correction:	ISP was updated to specify in detail services provided by the hospice provider to Resident #3. Resident Care Director and Assistant Resident Care Director will review ISPs of residents receiving hospice services and will specify in detail services provided by their hospice provider. Resident Care director will be responsible.