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. 20, 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 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:

A renewal inspection was initiated on 09/20/2021 and concluded on 09/21/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 50. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 3 resident records, 3 staff records, medication management plan, health care oversight, fire and health inspections, fire drill logs, dietician oversight and staff schedules, submitted by the facility to ensure documentation was complete. An exit interview was conducted with the Administrator on the date of inspection, 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 #:	22VAC40-73-320-A
Description:	Based on a review of resident records, the facility failed to ensure that physical examinations contained all required information. EVIDENCE: 1. The Physical examination dated 2/3/21 in the record for resident 1 does not contain a statement that specifies whether the individual is or is not capable of self-administering medication. 2. The Physical examination dated 5/14/21 in the record for resident 2 does not contain a statement that specifies whether the individual is or is not capable of self-administering medication.
Plan of Correction:	What Has Been Done to Correct- H&P form was updated 2/2018 to include required documentation of self-medication. Facility will audit resident charts to we have signed document regarding the ability to self-administer medication How Will Recurrence Be Prevented- All old copies of the CSL H&P will be disposed of. Education provided 9/28/2021
Standard #:	22VAC40-73-440-D
Description:	Based on a review of resident records, the facility failed to ensure that private pay uniform assessment instruments (UAIs) were completed as required. EVIDENCE: 1. The UAI dated 9/4/2021 for resident 3 is incomplete as it has documentation that the resident requires assistance with bathing, dressing, toileting, transferring and eating and feeding but does not specify what type of help is needed.
Plan of Correction:	What Has Been Done to Correct- Yardi support ticket was submitted to correct the error with software. How Will Recurrence Be Prevented- In the event of unavoidable computer errors, the facility designee will complete a paper UAI in it?s entirety until digital copy can be competed. Audit will be done to ensure all UAI?s are complete Person Responsible- Any UAI certified designee.
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). EVIDENCE: 1. The record for resident 1 has documentation of the resident needing oxygen therapy and using bed mats for fall risk. The uniform assessment instrument (UAI) dated 9/13/21 has documentation that the resident requires assistance with bowel and bladder, walking, wheeling and is spoon fed. The ISP dated 9/13/21 does not address these identified needs. 2. The UAI dated 7/27/21 in the record or resident 2 has documentation that the resident requires physical assistance with walking and wheeling. The ISP dated 7/27/21 does address this identified need. 3. The record for resident 3 has documentation that the resident has a DNR order dated 8/21/21. The ISP dated 9/1/21 in the record for resident 3 does not address this identified need.
Plan of Correction:	What Has Been Done to Correct- The facility will correct and individualize ISP?s to include individual needs as identified on the UAI. How Will Recurrence Be Prevented- Will provide education to ISP certified designees. Person Responsible- ED and RCD
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 9/14/21 for resident 1 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. 2. The comprehensive ISP dated 9/1/21 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:	What Has Been Done to Correct- The facility will correct the ISP to include detailed services provided by outside care partners. How Will Recurrence Be Prevented- Education will be provided to ISP certified designees. Person Responsible- ED and RCD
Standard #:	22VAC40-73-680-E
Description:	Based on a review of resident records, the facility failed to ensure that medical procedures and treatments ordered by a physician were documented. EVIDENCE: 1. The record for resident 1 has documentation on a Hospice comprehensive assessment and plan of care update report dated 8/13/2021 for oxygen 2 litters/min via nasal cannula as needed for low o2 sats less than 90%. Documentation in progress notes on several days indicate that resident 1 was wearing oxygen. The order for oxygen for resident 1 nor that dates that the resident was using oxygen was documented on resident 1's September 2021 medication administration record (MAR). 2. The record for resident 2 has documentation that the resident is receiving home health services for wound care needs. The September 2021 MAR for resident 2 does not have documentation of a physician order for wound care.
Plan of Correction:	What Has Been Done to Correct- The facility will identify procedures and treatments by outside care partners and will be documented on the ISP per 680 E documentation requirements and per CSL Policy. How Will Recurrence Be Prevented- RCD will communicate with home health providers as well as progress monthly per CSL policy. Person Responsible- RCD