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. 30, 2021

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

Comments:

A renewal inspection was initiated on 08/30/021 and concluded on 09/02/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 60. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed four resident records, and four staff records submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 09/01/2021. An exit interview was held with the administrator on 09/01/2021 and 09/02/2021, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-260-C
Description:	Based on observations made during the tour of the building, the facility failed to have a listing of all staff who have current certification in first aid or CPR posted in the facility readily available to staff. EVIDENCE: 1. There was not a posted list available in the facility with the staff members who are currently certified in CPR or first aid. 2. When the LI asked Staff #5 where the posting was, she denied the list was posted.
Plan of Correction:	Concierge posted CPR/FA list in pharmacy on AL. Concierge or designee will ensure compliance by checking the list weekly. [sic]
Standard #:	22VAC40-73-450-D
Description:	Based on review of resident records, the facility has failed to include the specifics of hospice care on the ISP for one resident. EVIDENCE: 1. Resident #1 has hospice documented as a service per the nursing notes from the previous three months and through the Hospice agency?s nursing notes. Hospice as a service is not addressed on Resident #1?s ISP.
Plan of Correction:	Resident Care Director updated Resident #1 ISP to reflect Hospice services. RCD or designee will review all ISP's moving forward to be sure that all needs are addressed. [sic]
Standard #:	22VAC40-73-450-F
Description:	Based on review of resident records, the facility has failed to include a description of identified needs and dates of three residents on their ISP. EVIDENCE: 1. Resident #1 has restraints (full bed rails) per the physician?s order dated for 07/27/2021. 2. Resident #1?s ISP does not include bed rails as an identified need. 3. Resident #1 has eating/feeding-needs to be spoon fed by others identified as a need on her UAI dated 03/03/2021. The UAI also documents that she is disoriented to some spheres, some of the time time-the sphere is identified as time. Her ISP dated 03/03/2021 does not address the need of eating/feeding nor the need for redirection when needed to time. 4. Resident #4 has a physical signed by a physician on 12/03/2020 which lists Codeine as an allergy. Resident #4?s ISP dated 03/12/2021 does not address the allergy to Codeine. 5. On page eight of Resident #4?s ISP dated 03/12/2021 it states the resident does not have visual impairment. On page five of the same ISP for the same resident it identifies he has a need to assist resident to put on glasses upon awakening; this is inconsistent. 6. Resident #3?s ISP has the following needs identified and documented on her ISP updated on 07/22/2021: Evacuation, Activities, Additional Services, Dressing, Escorts, Evacuation, Grooming/Personal Hygiene, Meal Consumption, Medication, Toileting, and Transferring. None of these identified needs have documentation on the ISP regarding the persons who will provide the services or when and where the services will be provided.
Plan of Correction:	Resident Care Director updated Resident #1, #3, and #4 UAI and ISP to address all current needs. Executive Director, Resident Care Director or designee will audit UAI and ISP upon completion to ensure all needs are addressed. All current Resident UAI and ISP will be reviewed and updated. [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on documentation review of the Medication Administration Record (MAR), the facility failed to follow their medication management plan to ensure that each resident?s prescription medications are filled and refilled and available in a manner to avoid missed dosage and to ensure that methods to ensure accurate counts of all controlled substance whenever assigned medication administration staff changes EVIDENCE: 1. Resident #3 has a physician?s order for Sertraline HCL 50mg tablets, one tablet by mouth every day for depression, anxiety signed on 12/08/2020. The MAR shows this medication as ?med not on cart? for 08/08/2021, and ?awaiting pharmacy? on 8/07/2021. 2. The ?Narc Count Sheet? located in memory care (A cart) did not have any documentation for the oncoming/off going 7am shift for the date of the inspection. The inspector arrived at the facility after 11:00 am. 3. There are two medication carts on Memory Care (Cart A and Cart B). The ?Narc Count Sheet? for Cart A and Cart B did not have documentation to distinguish which "Narc Count Sheet" belonged to which medication cart.
Plan of Correction:	Resident Care Director verified availability of medication for Resident #3. Resident Care Director educated RMA's on proper Narc count sheet documentation. Resident Care Director or designee to spot check MAR's and Narc sheets periodically to ensure compliance. [sic]
Standard #:	22VAC40-73-680-C
Description:	Based on observations made during the review of resident's Medication Administration Records (MAR), the facility failed to administer medications no earlier than one hour before and not later than one hour after the facility's standard dosing schedule, expect those drugs that are ordered for specific times, such as before, after, or with meals. EVIDENCE: 1. On 08/27/2021 Resident #4 had one medication scheduled for 10pm, however MAR documentation verifies this medication was not administered until 12:46am by Staff #6. 2. On 08/28/2021 Resident #4 had one medication scheduled for 10am, however MAR documentation verifies this medication was not administered until 11:40am by Staff #6. 3. On 08/10/2021 Resident #1 had one medication scheduled for 4pm and one scheduled medication at 5pm. Both of these medications were not administered until 8:15pm. The MAR documentation verifies these two medications were administered more than one hour late by Staff #6. 4. On 08/14/2021 Resident #1 had one medication scheduled for 5pm-administered at 8:15pm; one medication scheduled for 1pm-administerd at 5:53pm; one medication scheduled for 4pm-administered at 5:53pm; and one medication scheduled for 2pm-administered at 5:53pm. The MAR documentation verifies these four medications were administered more than one hour late by Staff #6. 5. On 08/15/2021 Resident #1 had one medication scheduled for 5pm and one medication scheduled at 4pm; both of these medications were administered at 6:36pm. The MAR documentation verifies that these two medications were administered more than one hour late by Staff #6. 6. On 08/19/2021 Resident #1 had one medication scheduled for 5pm- administered at 6:32pm. The MAR documentation verifies that this medication was administered more than one hour late by Staff #6. 7. On 08/20/2021 Resident #1 had one medication scheduled for 4pm-administered at 6:07pm. The MAR documentation verifies that this medication was administered more than one hour late by Staff #6. 8. On 08/24/2021 Resident #1 had one mediation scheduled for 1pm-administered at 2:12pm. The MAR documentation verifies that this medication was administered more than one hour late by Staff #6. 9. On 08/28/2021 Resident #1 had two medications scheduled for 4pm-both were administered at 6:16pm. The MAR documentation verifies that these two medications were administered more than one hour late by Staff #6.
Plan of Correction:	Resident Care Director reeducated Staff #6 on proper medication administration times for all residents. Resident Care Director or designee will check administration times weekly to ensure accuracy moving forward. [sic]
Standard #:	22VAC40-73-690-B
Description:	Based upon resident record review, the facility failed to have a licensed healthcare professional perform a medication review every six months for each resident in assisted living, except for those who self-administer heir own medications. EVIDENCE: 1. Resident #1 was admitted to the facility on 01/09/2020. The last documented pharmacy review available was dated 11/03/2020. 2. Resident #3 was admitted to the facility on 10/21/2020. The last documented pharmacy review available was dated 11/30/2020. 3. Resident #4 was admitted to the facility on 12/03/2020. The last documented pharmacy review available was dated 12/08/2020. 4. Staff #5 stated there was not a written, signed medication review in Resident #1, #2, and #3?s file.
Plan of Correction:	Executive Director contacted Pharmacy to conduct an additional Pharmacy Review. Executive Director will meet with the Pharmacist to discuss expectations during next audit. Resident Care Director or designee will have an exit meeting with Pharmacy to ensure all resident files were reviewed and all documentation needed was found. [sic]
Standard #:	22VAC40-73-690-F
Description:	Based on staff interview, the facility failed to have a licensed health care professional practicing within the scope of their profession to certify that a medication review had been completed, signed and dated and provided to the administrator in writing within ten days and maintained in the resident's file for at least two years. EVIDENCE: 1. When LI asked Staff #5 to explain how the facility documents the required pharmacy review, she was not able to produce any documentation to show the review had been completed and provided to the administrator within required days, nor was Staff #5 able to show these reviews in the resident's file.
Plan of Correction:	Executive Director contacted Pharmacy to conduct an additional Pharmacy Review. Executive Director will meet with Pharmacist to discuss expectations during next audit. Resident Care Director or designee will have an exit meeting with the Pharmacy to ensure all resident files were reviewed and all documentation needed was found, and all the documentation that the community needs was provided within a 10-day time frame. [sic]
Standard #:	22VAC40-73-700-1
Description:	Based on observations made reviewing resident records, the facility failed to have a valid physician?s order which included the oxygen source, such as compressed gas or concentrators for three residents. EVIDENCE: 1. Resident #1 has an oxygen order signed and dated by a physician or other prescriber on 07/27/2021. This order did not contain the source of oxygen such as compressed gas or concentrator. 2. Resident #5 has an oxygen order signed and dated by a physician or other prescriber on 05/26/2021. This order did not contain the source of oxygen such as compressed gas or concentrator. 3. Resident #6 has an oxygen order signed and dated by a physician or other prescriber on 09/23/2020. This order did not contain the source of oxygen such as compressed gas or concentrator.
Plan of Correction:	Resident Care Director received updated physicians order showing source of oxygen. All resident oxygen orders will be reviewed for deliver device per regulatory compliance. Resident Care Director or designee will educated providers on process for writing orders in ALF setting. [sic]
Standard #:	22VAC40-73-710-C
Description:	Based on review of resident records, the facility failed to have a physician?s order written that specifies the condition, circumstance, and duration under which a restraint is to be used for one resident out of four whose records were reviewed. EVIDENCE: 1. Resident #1 has a signed physician?s order dated for 07/27/2021 for full bed rails for a hospital bed, no conditions, circumstance, or duration was documented on this physician?s order.
Plan of Correction:	Community received DC order for full bed rails and received a start order for concave mattress to be sure for comfort and repositioning. Resident Care Director or designee will remind outside agency of policy in regards to DME orders. Train staff to report observations of full bed rails to RCD. RCD to do monthly community rounds to ensure there are no full bed rails in the building. [sic]
Standard #:	22VAC40-73-860-I
Description:	Based on observations made during the tour of the building, the facility failed to store hazardous materials in a locked area. EVIDENCE: 1. The mechanical room on the assisted living side of the building, located just off the dining room was found unlocked and unoccupied by staff. There were approximately five gallons of paint located in this unlocked room. 2. The sales and marketing office door on B hall was open, unlocked and did not have a staff member present when LI entered. There were two full boxes of Franzia wine sitting in the floor in this unlocked, unsupervised area. 3. While touring the Sweet Memories area of the building, outside of the Serenity Room in the middle, vertical desk drawer there was a one quart 12 ounce USG Sheetrock Dust Control Patch and Repair compound and an eight inch Marshalltown putty spatula found. The Sheetrock Patch and repair compound stated ?Keep Out Of Reach Of Children? on the container.
Plan of Correction:	Mechanical room was locked following LI observation. Wine was removed from SMD office. Sheetrock putty and spatula was removed from the drawer. Executive Director or designee will spot check various areas throughout the community weekly to assure compliance. [sic]