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: Jan. 24, 2023

Complaint Related: No

Areas Reviewed:

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 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: 01/24/2023 10:00am until 4:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 63 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 2 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-1100-A
Description:	Based on resident record review, the facility failed to obtain written approval from one of the required individuals prior to placing a resident in a safe, secure environment. EVIDENCE: 1. The record for resident 3 contained documentation that the resident was admitted to the facility?s safe, secure environment on 12/20/2022; however, the approval for placement in special care unit document for resident 3 was not signed or dated until 12/23/2022. The document also did not include the printed name of the individual who gave permission for the resident to be placed in the safe, secure environment.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-100-C-2
Description:
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure that a resident had a physical examination within 30 days preceding admission. EVIDENCE: 1. The record for Resident 2, admitted to the facility on 12/15/2022, has documentation on the third page of the report of physical examination that it was signed by the physician on 11/30/2022. The first page of the report of resident physical examination for resident 2 has that the date of examination was 10/24/2022, making it unclear if resident 2?s physical examination was completed within 30 days preceding his admission.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-325-B
Description:	Based on resident record review and staff interview, the facility failed to ensure a fall risk rating was reviewed and updated after a resident fell. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 8, dated 08/18/2022, indicates that the resident is assisted living level of care. 2. Hospital discharge documentation in the record for resident 8 indicates that the resident was sent out to the hospital on 10/16/2022 due to suffering a fall at the facility. The most recent fall risk rating provided during the on-site inspection on 01/24/2023 for resident 8 was dated 08/18/2022. Interview with staff 4 revealed that there was not a fall risk completed for the resident for the 10/16/2022 fall.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to ensure required resident personal and social information was obtained prior to or at the time of admission to an assisted living facility. EVIDENCE: 1. The resident-personal/social data sheet for resident 2, admitted 12/15/2022, did not contain or identify if the following information was applicable to the resident: service in armed forces, information on advance directives, legal representative, responsible individual, clergyman/place of worship, personal dentist, local department of social services, any other agencies, and current behavioral and social functioning. 2. The resident-personal/social data sheet for resident 1, admitted 12/16/2022, did not contain or identify if the following information was applicable to the resident: service in armed forces, allergies, information on advance directives, responsible individual, clergyman/place of worship, personal physician, personal dentist, local department of social services, any other agencies, and current behavioral and social functioning.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review and staff interview, the facility failed to ensure private pay uniform assessment instruments (UAIs) were completed as required. EVIDENCE: 1. The UAI for resident 1, dated 11/23/2022, indicated that the resident?s medication are administered/monitored by professional nursing staff; however, the facility also employees registered medication aides which are considered laypersons and not licensed professional nursing staff. 2. The UAI for resident 2, dated 11/24/2022, indicated that the resident?s medication are administered/monitored by professional nursing staff; however, the facility also employees registered medication aides which are considered laypersons and not licensed professional nursing staff. The UAI for resident 2 also indicates that resident 2 requires mechanical assistance with wheeling; however, interview with staff 3 revealed that this is incorrect and that the resident does not require assistance as he does not use a wheelchair. 3. The UAI for resident 3, dated 01/09/2023, indicated that the resident requires human physical assistance only with bathing; however, the individualized service plan (ISP) for resident 3, dated 01/09/2023, indicated that the resident requires human physical assistance and mechanical assistance with bathing. Interview with staff 4 revealed the ISP is correct and the UAI is incorrect. 4. The UAI for resident 6, dated 11/04/2022, indicated that the resident?s medication are administered/monitored by professional nursing staff; however, the facility also employees registered medication aides which are considered laypersons and not licensed professional nursing staff. 5. The UAI for resident 7, dated 01/23/2023, indicated that the resident?s medication are administered/monitored by professional nursing staff; however, the facility also employees registered medication aides which are considered laypersons and not licensed professional nursing staff. Also the UAI has documentation that resident 7 is alert and oriented to all spheres but an assessment of serious cognitive impairment completed by the residents physician on 09/06/2022 has documentation that resident 7 has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and is unable to recognize danger or protect their own safety and welfare. An interview with staff 3 revealed that the UAI is incorrect.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure individualized service plans (ISPs) contained all required information. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 2, dated 11/24/2022, indicated that the resident has bladder incontinence less than weekly and requires mechanical help and human physical assistance with stairclimbing; however, these identified needs are not addressed on the resident?s ISP, dated 11/24/2022. Interview with staff 2 revealed that the UAI is correct meaning both are identified needs that should be included on the resident?s ISP. 2. The ISP for resident 3, dated 01/09/2023, contained documentation that the resident may require assistance with closed drainage system/catheter. Interview with staff 4 revealed that the resident does not have a closed drainage system/catheter. Also, the UAI for resident 3, dated 01/09/2023, indicated that the resident is disoriented ? all spheres, some of the time to person, place and time; however, the aforementioned information was not included on the resident?s ISP dated 01/09/2023. Interview with staff 4 revealed that this information should be on the resident?s ISP. 3. The record for resident 1 has a signed Do Not Resuscitate ?DNR? dated 12/28/2022. The report of physical examination dated 120/01/2022 in the record for resident 1 has an order for a low carb/diabetic diet and for physical therapy for an unsteady gait. The ISP dated 12/23/2022 in the record for resident 1 does not address these identified needs. 4. The record for resident 7 has a signed Do Not Resuscitate ?DNR? dated 08/30/2022, signed physicians orders dated 12/19/2022 for speech therapy evaluation and treatment as indicated and signed physician orders dated 01/19/2023 for wound care treatment twice a week. The ISP dated 01/23/2023 in the record for resident 7 does not address these identified needs.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-480-C
Description:	Based on review of resident records and staff interviews, the facility failed to ensure arrangement for specialized rehabilitative services by qualified personnel as needed by the resident. EVIDENCE: 1. The record for resident 1, admitted to the facility on 12/16/2022, has documentation of a physician order for physical therapy for unsteady gait/mobility on the report of physical examination dated 12/01/2022. As of the day of inspection, there was no documentation to support that resident 1 is receiving physical therapy. Interviews with staff 3 and 4 revealed that resident 1 is not currently receiving physical therapy services.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-610-D
Description:	Based on resident record review, document review, observation and staff interview, the facility failed to ensure when a diet is prescribed for a resident by his physician or other prescriber it is prepared and served according to his physician?s or other prescriber?s orders. EVIDENCE: 1. During an on-site inspection on 01/24/2023, staff 6 explained to both LI?s in the presence of staff 3 that the dietary staff follow a bulletin board posted in the kitchen and also a spread sheet in regards of identifying which residents have special diets that dietary staff need to prepare and serve according to physician?s orders. 2. Both aforementioned methods indicated that resident 5 is to be served a no concentrated sweets diet and 1800 calorie daily diet; however, the record for the resident did not include a signed physician?s order for the resident to be on an 1800 calorie daily diet. 3. A signed physician?s order in the record for resident 5, dated 12/05/2022, indicated that the resident is to be served a no concentrated sweets diet. The most recent dietitian review, dated 01/12/2023, contained documentation that resident 5 had a 3.6 pound weight loss in four months and for the facility to continue serving the resident a no concentrated sweets diet. The aforementioned information was also noted by staff 3.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-640-A
Description:	Based on observation during medication cart audit, document review and staff interview, the facility failed to implement a section of its medication management plan. EVIDENCE: 1. At approximately 10:54AM during an on-site inspection on 01/24/2023, it was observed by two licensing inspectors (LI?s) and staff 3 that the Levemir insulin pen for resident 9 located in medication cart three was opened but did not contain a date in which the insulin pen was opened by medication staff. The manufacturer?s instructions for Levemir state that the insulin expires 42 days after being opened. 2. The facility?s medication management plan indicates that outdated, damaged, or contaminated medications are not to be used and are to be disposed, medication aides are responsible for identifying outdated, damaged, or contaminated medications and all medication aides are to confirm expiration dates of medications during the medication pass. Interview with staff 4 revealed during a preliminary exit interview on 01/24/2023 that medication staff are to make sure to write on insulin pens and vials the date they were opened to ensure that expired insulin is not administered to residents.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observations made during an on-site inspection, the facility failed to ensure that medications were stored in a locked area. EVIDENCE: 1. At approximately 10:30AM during the on-site inspection, both LI?s and staff 3 observed a round, white pill printed with the number four lying on the floor in the hallway by the medication cart that was sitting outside of the assistant resident care director?s room.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-860-I
Description:	Based on observations made during an on-site inspection of the facility?s physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: 1. A bottle of Modeso Nail Polish Remover and 3 bottles of Stato Ecolution Probiotic Floor cleaner were observed by both LI?s and staff 3 in the unlocked cabinets in the unlocked laundry room across from room 420. 2. A box containing 4 packs of Lysol Disinfectant Wipes was observed by 2 LI?s and staff 3 in the unlocked closet across from the kitchen.
Plan of Correction:	Not available online. Contact Inspector for more information.