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: March 31, 2022

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

Two licensing inspectors conducted a one day renewal inspection at Commonwealth Senior Living at Radford on 03/31/2022, the inspection began at 10:15 am and concluded at 3:29 pm. The facility had 68 residents in care on the day of the inspection. The focus of this inspection was to look at previous violations, monitor compliance with standards and the plan of correction and to conduct a full licensing renewal study. Required postings were checked, the building was observed, the noon medication pass was observed and medication carts and medication administration records were audited. Lunch and snacks were observed being served as well as activities taking place. Staff and resident interactions were witnessed. Background checks and sworn disclosure were reviewed for all new hires. An exit meeting was held with the administrator on 03/31/2022 and at that time an opportunity was given to find items that were not readily available in files. As a result of this inspection, six 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 (03/23/2022) 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 #:	22VAC40-73-1100-A
Description:	Based on resident record review, the facility failed to ensure that prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval of one of the following persons, in the following order of priority: The resident, if capable of making an informed decision; a guardian or other legal representative for the resident if one has been appointed; a relative who is willing to take responsibility to act at the resident?s representative; an independent physician who is skilled and knowledgeable in the diagnosis and treatment of dementia. EVIDENCE: The ?Approval for Placement in Special Care Unit? form for Resident #9, dated 2/21/2022, was marked with an ?X? next to ?Guardian or legal representative for the resident? and ?Adult child?; however, the form had no signature of those individual(s) who were marked as approving placement of this resident in the special care unit.
Plan of Correction:	Verbal consent was received prior to placement of resident on secure unit. Power of Attorney was contacted and provided with documentation to sign regarding resident residing on secure unit. BOM or designee will ensure that all proper documentation is completed prior to secure unit/transfer. ED & BOM [sic]
Standard #:	22VAC40-73-1180-A
Description:	Based on observation, the facility failed to ensure that when there are indications that ordinary materials or objects may be harmful to a resident in a safe, secure environment, these materials or objects shall be inaccessible to the resident except under staff supervision. EVIDENCE: During the physical plant tour of the facility?s memory care unit on the date of inspection at approximately 11:20 AM, the LI entered the Serenity Room and observed an electric fireplace running which was in front of the loveseat. LI noted that the Serenity room was warm, and touched the top of the fireplace to ensure that residents could not be burned if coming into contact with the fireplace. As a result the LI felt a scalding hot surface, and noted the Serenity Room and the electric fireplace was accessible to all memory care residents.
Plan of Correction:	Maintenance Director replaced electric fireplace with a new one that does not get hot to the touch. ED and Maintenance Director to inspect periodically during maintenance walk thru. ED & Maintenance Director [sic]
Standard #:	22VAC40-73-440-D
Description:	Based on observations made during resident record review, the facility failed to ensure that for private pay individuals, the uniform assessment instrument (UAI) is completed as required. EVIDENCE: 1. The standards for Licensed Assisted Living Facilities, effective 10/13/2021, define ?Assisted Living Care? as a level of service for adults who may have physical or mental impairments and require at least moderate assistance with the activities of daily living (ADLs). Alternately, the standards for Licensed Assisted Living Facilities, define ?Residential Living Care? as a level of service for adults who may have physical or mental impairments and require only minimal assistance with ADLs. 2. The UAI for Resident #3, dated 3/3/2022, indicated that this resident has been assessed at the assisted living level of care; however, the UAI indicated that the resident does not require assistance with any ADLs.
Plan of Correction:	Resident #3 UAI & ISP correct to reflect assistance that is provided. RCD or designee to accurately list assistance needed in UAI and ISP?s moving forward. ED, RCD & ARCD [sic]
Standard #:	22VAC40-73-450-C
Description:	Based on observations made during review of resident records, the facility failed to include a start date and/or expected outcome dates for each service listed on the Individualized Service Plan (ISP). EVIDENCE: 1. Resident #1 does not have any start dates or expected outcome dates listed for any of the services listed on her ISP.
Plan of Correction:	Resident #1 ISP correct to reflect start date and expected outcome date. RCD or designee to verify that all required information is printed out on ISP?s moving forward. ED, RCD & ARCD [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on record review, the facility failed to implement its medication management plan with regard to methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The controlled substance shift counts according to the medication management plan, dated 12/15/2021, states ?Shift counts are performed at the end of each shift or when the person responsible for medications changes?Whenever a Med Aide leaves the floor and another Med Aide is responsible for meds, a complete count will take place by the person going off the cart and the person coming on the cart?4. If the quantity is verified, the off-going and on-coming Med Aides both sign the appropriate Controlled Substance Shift Count form.? The facility?s MMP also states ?5. If the quantities differ, (a) The off-going and on-coming Med Aides will perform a recount to ensure a simple counting error was not made? (c)? medication not used according to the MAR or PRN record, this must be documented on the Controlled Substance Shift Count form and the Executive Director notified immediately.? 2. During the facility?s medication cart audits at approximately 10:29 AM and 10:42 AM, the LI viewed Narcotic Shift Count logs for two medication carts in the assisted living unit of the facility. As a result the LI observed incomplete narcotic count documentation for the following dates and times: For D-Hall cart, on 3/1/2022, for the 7 AM to 2 PM shift, the oncoming medication administration staff member did not sign the log; On 3/23/2022, for the 11 PM to 7 AM shift, the oncoming staff member did not sign the log and the Count Discrepancies Found box was incomplete; On 3/24/2022, for the 7 AM to 7 PM shift, the off-going staff member did not sign the log; On 3/29/2022, for the 11 PM to 7 AM shift, the off-going staff member did not sign the log. For B-Hall cart, on 2/25/2022, for the 7 AM to 3 PM shift, the off-going staff member did not sign the log; On 3/1/2022, for the 7 AM to 2 PM shift, the oncoming staff member did not sign the log; On 3/14/2022, for the 7 AM to 3 PM shift, the off-going staff member did not sign the log; On 3/17/2022, for the 11 PM to 7 AM shift, the oncoming staff member did not sign the log; On 3/17/2022, for the 7 AM to 3 PM shift, the off-going staff member did not sign the log; On 3/29/2022, for the 3 PM to 11 PM shift, the oncoming staff member did not sign the log; On 3/30/2022, for the 11 PM to 7 AM shift, the off-going staff member did not sign the log and the Count Discrepancies Found box was incomplete; On 3/30/2022, for the 3 PM to 11 PM shift, the oncoming staff member did not sign the log and the Count Discrepancies Found box was incomplete; On 3/30/2022, for the 11 PM to 7 AM shift, the oncoming and off-going staff members did not sign the log; On 3/31/2022, for the 7 AM to 3 PM shift, the oncoming staff member did not sign the log.Discrepancies Found box was incomplete; On 3/30/2022, for the 3 PM to 11 PM shift, the oncoming staff member did not sign the log and the Count Discrepancies Found box was incomplete; On 3/30/2022, for the 11 PM to 7 AM shift, the oncoming and off-going staff members did not sign the log; On 3/31/2022, for the 7 AM to 3 PM shift, the oncoming staff member did not sign the log.
Plan of Correction:	ARCD contacted all Medication Aides on said shifts to verify cart count was completed and all Medication Aides were aware of the policy regarding narcotic medication counting ED and ARCD held in-service and re-educated all Medication Aides on proper narcotic procedure per our Med Management Plan. RCD, ARCD & ED [sic]
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair. EVIDENCE: 1. During the morning tour of the safe secure unit at approximately 11:30 AM, the LI observed a wall outside of the dining room, had black horizontal marks as well red or purple finger marks on the same wall, near the whiteboard.
Plan of Correction:	Maintenance Director repainted area outside dining room. Weekly maintenance walk-thru to be completed by ED and Maintenance Director. ED & Maintenance Director. [sic]