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: Jan. 13, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS

Comments:

One licensing inspector and one licensing administrator conducted an unannounced non-mandated focused inspection on 01/13/2022. The inspection began at 10:10 am and concluded at 1:05 pm. This inspection was conducted to review previous violations. As a result of this inspection, three violations are being cited. An exit meeting was conducted with the administrator on 01/13/2022 and at that time, the findings were discussed and opportunity was given to find items that were not available in the records. A corrective action plan should be developed addressing steps to correct the noncompliance of each standard; measure(s) to prevent the re-occurrence; and the person(s) responsible for implementing each step and/or monitoring and prevention measures(s). The "description of action to be taken" for each violation, along with the "date to be corrected" must be returned to this office signed and dated within 10 calendar days (02/06/2022) of receipt. If you have any questions or concerns please contact your inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-650-A
Description:	Based on observations made during the review of the MAR (Medication Administration Record) and physician's orders, the facility failed to ensure no medication or treatment be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. EVIDENCE: 1. Resident #2 is prescribed Calmoseptine Ointment, apply topically to groin twice daily as needed per a physician's order dated 12/27/2021. The packaging for the Ointment states apply as needed. The MAR states apply every shift. The MAR indicates the ointment is administered every shift. 2. Resident #2 is prescribed Ferrous Sulfate 325mg tablet, take one tablet by mouth daily per a physician's order dated 12/27/2021. The packaging for the Ferrous Sulfate says take daily. A physician's order dated for 12/14/2021 states to take Ferrous Sulfate 325 mg tablet, every other day. The MAR states to take one tablet of Ferrous Sulfate every other day.
Plan of Correction:	Obtained orders from PCP of Resident #2 clarifying directions for Calmoseptine Ointment and ferrous Sulfate. Error has been corrected. Executive, Resident Care Director and/or Assistant Resident Care Director will review all new orders and packaging upon medication changes and monthly moving forward to ensure that no change of directions are looked over. To assure medication compliance; this audit will be ongoing for all future items as well. [sic]
Standard #:	22VAC40-73-650-E
Description:	Based on observations made during review of resident records, the facility failed to chronologically file all physician's or other prescriber's signed orders in a resident's record . EVIDENCE: 1. Resident #2 had physician's orders dated 12/15/2021, 12/17/2021, and 12/28/2021. When LI requested the orders, Staff #1 had to locate them in a stack of papers, to be filed.
Plan of Correction:	RCD completed filing of all outstanding documents for each resident. RCD or designee will ensure all filing is kept up to date. [sic]
Standard #:	22VAC40-73-680-M
Description:	Based on observations made during an audit of a medication cart, the facility failed to have medications ordered for PRN (as needed) administration available and properly stored at the facility. EVIDENCE: 1. Resident #2 was prescribed Voltarin Gel 1% to be applied to shoulder and knee every eight hours as needed. This order was dated 12/15/2021. This medication was not available to the resident on the medication cart and was not listed on the MAR (Medication Administration Record). 2. Resident #2 is prescribed Albuterol 90MCG, inhale two puffs by mouth every four hours as needed for shortness of breath. This order was dated 12/15/2021. This medication was not available to the resident on the medication cart.
Plan of Correction:	Order has been received from pharmacy on same date inspection was completed (1-31-2022) for Resident #2. Error has been corrected. Executive Director, Resident Care Director and/or Assistant Care Director will adult PRN's for all residents monthly to ensure that all PRN's are being used, are in date and available for all residents moving forward. To assure assure medication compliance; this audit will be ongoing for all future items as well. [sic]