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: Aug. 22, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/22/2022 9:00am until 4:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing regarding allegations in the areas of: Resident care and related services and additional requirements for facilities that care for residents with serious cognitive impairments. Number of residents present at the facility at the beginning of the inspection: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-325-B
Description:	Based on resident record review, the facility failed to ensure fall risk ratings were reviewed and updated after a fall for all residents who are assessed as assisted living level of care. EVIDENCE: 1. The record for resident 1, has documentation that the last fall risking rating completed for this resident was dated 04/01/2022. 2. The record for resident 1 has documentation in progress notes on 06/26/2022 of the resident sliding to the floor, requiring emergency room services. Progress notes for resident 1 also has documentation on 07/17/2022 of the resident being very weak while trying to sit in a chair, lost his balance and was lowered to the floor by staff. On 08/06/2022 progress notes in the record for resident 1 has documentation that the resident was observed with dried blood on his forehead with a skin tear above his right brow and on his right elbow and dried blood was observed on the floor at the foot of his bed. Resident 1 was sent to the emergency room for evaluation. Progress notes in the record for resident 1 has documentation on 08/08/2022 of the resident being found in the floor near the dining room and that the resident was complaining of foot/ankle pain and sent to the emergency room for evaluation. A fall risk rating was not noted for any of these subsequent falls.
Plan of Correction:	Fall risk assessments completed 4/1/22, 6/26/22, 7/17/22 and 8/6/22. RCD educated on completing fall risk rating with each fall per regulation. RCD and or designee will complete fall risk rating ongoing with each fall. RCD or Designee
Standard #:	22VAC40-73-440-D
Description:	Based on a review of resident records, the facility failed to ensure that uniform assessment instruments (UAI?s) were completed as required. EVIDENCE: 1. The private pay UAI dated 04/06/2022 in the record for resident 1 has documentation that the resident has an appropriate behavior pattern. This is inconsistent with documentation on a history and physical dated 04/05/2022 in the record for resident 1 that indicates resident 1 has Alzheimer?s with behavioral disturbances. Progress notes in the record for resident 1 has documentation on several dates of resident 1 wandering, roaming in and out of other residents rooms and becoming agitated and difficult to redirect.
Plan of Correction:	Resident 1 UAI will be corrected to reflect wandering and roaming behaviors as indicated on H&P. RCD reeducated on correctly completing UAIs with accurate information to match H&Ps. RCD or Designee
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The record for resident 1, admitted to the facility on 04/05/2022, has documentation on a history and physical dated 04/05/2022 in the record for resident 1 that indicates resident 1 has Alzheimer?s with behavioral disturbances. Progress notes in the record for resident 1 has documentation on several dates of resident 1 wandering, roaming in and out of other residents rooms and becoming agitated and difficult to redirect. The ISP with an activation date of 04/10/2022 does not address these identified needs.
Plan of Correction:	Resident 1 ISP will be corrected to reflect wandering and roaming behaviors as indicated on H&P. RCD reeducated on correctly completing ISPs with accurate information to match H&Ps. RCD or designee