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: April 4, 2023

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 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: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/04/2023 Start: 10:50am finish:5:15pm 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: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 14 Number of staff records reviewed: 29 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: 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 Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1110-B
Description:	Based on resident record review, the facility failed to document the review of appropriateness six months after placement in the special care unit and then annually thereafter for two residents. EVIDENCE: 1. Resident #4 was admitted to the special care unit on 10/27/2016. The last review of appropriateness for continued placement was signed on 04/21/2021 by the administrator of the facility at that time. 2. According to staff #8, resident #4 still resides on the special care unit as of 04/04/2023 and staff #8 states there have not been any reviews since 04/21/2021. 3. Resident # 8 was admitted to the special care unit on 05/18/2021. The last review of appropriateness for continued placement was signed on 06/18/2021 by the administrator of the facility at that time. 4. According to staff #8, resident #8 still resides on the special care unit as of 04/04/2023 and staff #8 states there have not been any reviews since 03/03/2022. 5. Resident #6 was admitted to the special care unit on 01/06/2022. The last review of appropriateness for continued placement was signed on 03/22/2022 by the administrator of the facility at that time. 6. According to staff #8, resident #6 still resides on the special care unit as of 04/04/2023 and states there are no additional reviews in resident #6?s file.
Plan of Correction:	ED will review current Memory Care resident files to ensure that all appropriateness for continued placement is up to date and meets annual review compliance standards. [sic[
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to include all the required information on the physical examination report within 30 days preceding admission to an assisted living facility for one resident. EVIDENCE: 1. Resident # 3 had a physical exam completed on 07/06/2021; her admission date was 07/10/021. The physical documented allergies to penicillin and Celebrex, but there were no reactions documented.
Plan of Correction:	ED, BOM, and/or designated person in charge will review and inspect all new admission documentation ensure that required information on the physical examination report is correct and relevant and the physical exam is completed within 30 days preceding admission to community and available at community prior to admission. [sic]
Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to include all required information on the resident personal and social information sheet prior to or at the time of admission for three residents. EVIDENCE: 1. Resident #1 was admitted to the facility on 01/27/2023. On the date of the inspection, 04/04/2023, the address, allergies, and DNR status were blank for resident #1?s personal and social information sheet. 2. Resident #2 was admitted to the facility on 07/12/2021. On the date of the inspection, 04/04/2023, the following information was left blank on the personal and social data information sheet for resident #2; armed forces, current behavior and social functioning, strengths, and problems. 3. Resident # 8 was admitted to the facility on 05/20/2021. On the date of the inspection, 04/04/2023, the admit date, legal representative, clergyman/place of worship and responsible party were blank on resident #8?s personal and social information sheet.
Plan of Correction:	ED, BOM, and/or designated person in charge will review and update, if applicable, with current and correct information in both business office file and clinical file for all social data sheets on current and active residents. [sic]
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review, the facility failed to ensure the UAI for private pay individuals (Uniform Assessment Instrument) is completed required by 22 VAC 30-110. EVIDENCE: 1. Resident #1 had a UAI completed on 01/30/2023 that indicates medication will be administered/monitored by professional nursing staff, and the name of helper is listed as ?LPN or med tech?. 2. Resident #5 had a UAI completed on 03/29/2023 that indicates medication will be administered/monitored by professional nursing staff, and the name of the helper is listed as ?LPN or med tech?. 3. Resident #2 had a UAI completed on 02/28/2023 that indicates medication will be administered/monitored by professional nursing staff, and the name of the helper is listed as ?LPN or med tech?. 4. When med techs are going to be administering medications, ?administered/monitored by lay person? must be checked on the UAI.
Plan of Correction:	ED, BOM, and/or designated person in charge will evaluate, review, and revise UAI?s to ensure proper documentation that will reflects the residents need for medication administration. [sic]
Standard #:	22VAC40-73-450-C
Description:	Based on review of resident records, the facility failed to include identified needs and the date identified on ISPs (Individual Service Plans) for two residents based upon information from the UAI (Uniform Assessment Instrument). EVIDENCE: 1. The UAI for resident # 3 completed on 10/07/2022 identifies bowel and bladder incontinence as a need. The ISP completed on 01/28/2023 did not include these needs.
Plan of Correction:	ED, BOM, and/or other designated person in charge will review and revise, if applicable, all ISP?s to ensure that both UAI and ISP correctly reflects the residents needs. [sic]
Standard #:	22VAC40-73-550-G
Description:	Based on resident record review, the facility failed to review with two residents or his legal representative the resident rights on an annual basis EVIDENCE: 1. Resident #3?s last resident rights review was documented on 01/31/2022. 2. Resident #9?s last resident rights review was documented on 09/28/2021. 3. Staff # 8 stated there were no more current reviews of resident rights for resident # 3 or # 9.
Plan of Correction:	ED, BOM, and/or designated person in charge will review current resident files to ensure that resident rights have been reviewed with resident or his legal representative. ED, BOM, and/or designated person in charge will update files that are out of compliance. [sic]
Standard #:	22VAC40-73-680-C
Description:	Based on observations made during the morning medication pass, the facility failed to ensure medications are administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after or with meals. EVIDENCE: 1. The April 2023 MAR for resident #1dicates the ten medications the LI observed being administered during the medication pass are to be administered at 8:00am. The LI observed staff # 1 administer the following medications to resident # 11 at 10:13am: Amlodipine 2.5mg tablet, Aspirin EC 81 mg tablet, Calcium 600mg Vit D 400 tablet, Docusate Sod 100mg Softgel, Duloxetine 30mg capsule, Ferrous Sulfate 325mg tablet, Hctz 12.5mg tablet, PEG3350 POW, Therems-M Tab, Zinc Sulf 220mg (50) capsule. 2. The April 2023 MAR for resident # 12 indicates the three medications the LI observed being administered during the medication pass are to be administered at 8:00am. The LI observed staff # 1 administer the following medications at 10:25am: Metoprolol Succ ER 25mg tab, Ocuvite w/Lutein tablet, Valsartan/Hctz 160-12.5mg tab. 3. The April 2023 MAR for resident # 14 indicates the eight medications the LI observed being administered during the medication pass are to be administered at 8:00am. The LI observed staff # 1 administer the following medications at 10:35am: Cranberry Concentrate 500mg, D-Mannose 500mg capsule, Eliquis 2.5mg tablet, Escitalopram 10mg tablet, Methenamine 1gm tablet, Propanolol 20mg tablet, Timolol 0.5% Opth Sol 5ml, Topiramate 50mg tablet. 4. The April 2023 MAR for resident # 13 indicates the five medications the LI observed being administered during the medication pass are to be administered at 9:00am. The LI observed staff # 1 administer the following medications at 10:49am: Aspirin EC 81mg tablet, Bupropion ER (SR) 200mg tablet, Galantamine ER 8mg capsule, Lisinopril 5mg tablet, Vitamin D3 50mcg (2000IU) tab.
Plan of Correction:	During review of med pass with Staff #1 by ED/BOM, it was determined that Staff #1 arrived late to work, without notification to the appropriate persons, which caused significant delay in her med pass. This was addressed with Staff #1 and corrective action was provided. Med times are being reviewed and appropriately adjusted to assure that each medication pass can be appropriately managed per regulatory standard of an hour before/hour after. Current RMAs will attend Annual RMA Refresher Training with Southern Pharmacy. Training to be completed by 4/30/2023. Med Pass Competencies will be completed on new and current RMAs by community nurse/designee. These competencies will be completed by 5/19/2023 and will be ongoing to meet regulatory standards. The RCD/designee will complete regular, random audits of medication pass to assure medications are being passed within regulatory standards. Continued concerns will be addressed appropriately up to termination of employment. [sic]
Standard #:	22VAC40-73-680-D
Description:	680D (B2) Based on observations during the morning medication pass, the facility failed to ensure medications are administered in a manner consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. The current medication aide curriculum approved by the Virginia Board of Nursing (revised 2022) states medication aides must ?Perform appropriate hand hygiene before and after all procedures.? (Unit 2: Preparing for Safe Administration of Medications, section 1-B-2.) 2. The LI did not observe staff # 1 perform hand hygiene after administering medication to resident # 11 and before administering medication to resident # 12, after administering medication to resident #12 and before administering medication to resident # 14 after administering medication to resident # 14 and before administering medication to resident # 13.
Plan of Correction:	Current RMAs will attend Annual RMA Refresher training with Southern Pharmacy. Training will be completed by 4/30/2023. ED, BOM, and/or designated person in charge will review proper hand hygiene techniques with all associates at scheduled mandatory all staff Inservice on 4/25/2023. Employees that are not in attendance will be assigned by BOM Infection Control module on Relias, if applicable, employees assigned Relias module will be expected to complete assigned module 10 days after the assignment date. ED, BOM, and/or designated person in charge will ensure staff have access to supplies that will allow them to always practice proper hand hygiene. [sic]
Standard #:	22VAC40-73-680-E
Description:	Based on observations during the medication cart audit and interviews with one resident and staff, the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber are provided according to his instructions. EVIDENCE: 1. The MAR dated 04/01/2023 to 04/04/2023 and physician's order most recently signed on 02/14/2023 indicates resident # 14 is prescribed Tubigrips, apply double layer of Tubigrips to bilateral lower extremities every morning and remove every night due to edema. 2. Staff initialed the MAR on 04/01/2023, 04/02/2023, 04/03/2023 and 04/04/2023 indicating the Tubigrips were applied as ordered. 3. The Tubigrips were not found to be stored in the medication cart and staff # 1 and staff # 14 reported they were most likely stored in resident # 14?s room. 4. Per interview with resident # 14 on 04/04/2023 at 3:04p.m., the Tubigrips are not stored in her room. 5. Resident # 14 was not wearing the Tubigrips at the time of the interview with LI and reports they are not being used.
Plan of Correction:	Physician ordered to discontinue Tubigrips on 4/13/2023 and to start utilizing TED Hose for Resident #14. Multiple pairs of TED Hose have been ordered from pharmacy. Current RMAs will attend Annu al RMA Refresher training with Southern Pharmacy. Training will be completed by 4/30/2023. For the next 30 days the Resident Care Director or designee will complete regular, random checks to assure that TED Hose are worn or appropriate documentation is available as to why not being worn. [sic]
Standard #:	22VAC40-73-680-H
Description:	Based on a review of medication administration records (MARs) and interviews with staff, the facility failed to document on the MAR all medications administered to residents, including over-the-counter medications and dietary supplements, for one of the four resident records reviewed. EVIDENCE: 1. The MAR for resident # 13 dated 04/01/2023-04/04/2023 and physician?s order most recently signed on 10/27/2022 indicate resident # 13 receives Atorvastatin 20mg tablet, take one tablet by mouth at bedtime for hyperlipidemia (start date 01/26/2022). 2. There were no staff initials on the MAR indicating the 9PM dose on 04/01/2023 had been administered to resident # 13. 3. Staff # 8 and staff # 14 were unable to locate documentation regarding the missing staff initials on the MAR for resident # 13.
Plan of Correction:	Current RMAs will attend Annual RMA Refresher training with Southern Pharmacy. Training will be completed by 4/30/2023. Refresher training to QuickMAR, community eMAR system, will also be completed to assure understanding in appropriately signing off on MAR after pass to each resident. Training will be provided to RCD and ED on review of eMAR system to assure that medications have been appropriately signed off by appropriate med tech, per physician?s order.. For the next 30 days, RCD/designee will complete a regular review of MARs to assure medications have been administered and signed for per physician?s order. [sic]
Standard #:	22VAC40-73-680-M
Description:	Based on observations made during the medication cart audit and interview with staff, the facility failed to ensure medications ordered for PRN administration are available and stored properly at the facility for two of the four resident records reviewed. EVIDENCE: 1. The MAR dated 04/01/2023 ? 04/04/2023 and physician?s orders signed most recently on 02/14/2023 indicate resident # 11 is prescribed Oxycodone IR 5mg tablet, take one tablet by mouth every six hours as needed for pain (control) (start date 08/26/2022). 2. The MAR dated 04/01/2023 ? 04/04/2023 and physician?s orders signed most recently on 02/14/2023 indicate resident # 14 is prescribed Hydroxyzine Pamoate 25mg caps, take one capsule by mouth every 6 hours as needed for anxiety/pain (give around 1200 prior to derm appt for increased anxiety) (start date 12/29/2022). 3. Per medication cart audit and interview with staff # 1, the abovementioned medications were not available at the facility for resident # 11and resident # 14, respectively.
Plan of Correction:	Oxycodone IR 5mg, for resident #11, and Hydroxyzine 25mg, for resident #14, have been discontinued by NP due to non-use in greater than 90 days. Audit of med cart will be completed by Southern Pharmacy by 4/27/2023 Audit of PRNs not utilized in greater than 90 days has been completed and discontinue orders have been requested from residents? physicians. [sic] Current RMAs will attend Annual RMA Refresher training with Southern Pharmacy. Training will be completed by 4/30/2023.
Standard #:	22VAC40-73-860-I
Description:	Based on observations made during a tour of the building, the facility failed to ensure cleaning supplies were stored in a locked area. EVIDENCE: 1. At approximately 9:59 a.m., the LI observed that the door to the laundry room located next to the private dining room was unlocked and the laundry room was unattended. 2. The LI observed two bottles of Zep Concentrated Premium Carpet Shampoo, two bottles of Triple Quick Lavender Meadow Disinfectant Cleaner, two buckets of Pyxis Laundry Solutions Enzyme Detergent, one bottle of NDC Morning Fresh Neutral Disinfectant Cleaner and one bottle of Ecolution Pro Glass Cleaner, all of which contain the warning, KEEP OUT OF REACH OF CHILDREN. 3. At 10:59 a.m., the LI noted that the door to the storage room remained unlocked and unattended.
Plan of Correction:	ED, BOM, and/or designated person in charge to post signage on all doors containing hazardous materials to keep area locked and secure when left unattended. ED, BOM, and/or designated person in charge will review with all staff at Mandatory Inservice Meeting on 4/25/2023. [sic]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during a tour of the building, the facility failed to ensure the interior and exterior of all buildings are maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. In the courtyard to the left upon entering the dining room from the main entrance, the LI observed a large pile of leaves and other debris near the grill covering an area of approximately 2 feet by 2 feet. 2. In the same courtyard, the LI observed a piece of fabric that appeared to be a curtain or part of a canopy lying on the ground and partially on the walkway. This could present a trip hazard. 3. In the same courtyard, the LI observed one of the raised gardens has collapsed, making it unusable for residents. 4. In the same courtyard, the LI observed a hanging birdfeeder to be lying on the ground. 5. In the courtyard to the right upon entering the dining room from the main entrance, the LI observed a window shutter lying on the ground in a mulched area behind one of the benches.
Plan of Correction:	Large pile of leaves and other debris cleared 4/5/2023. Canopy/Fabric cleared 4/5/2023. Raised garden removed 4/12/2023. Hanging birdfeeder restored and is in an upright position 4/12/2023. Displaced window shutter removed from ground (mulched area) behind left bench 4/12/2023. [sic]
Standard #:	22VAC40-73-970-A
Description:	Based on staff interviews and documentation, the facility failed to conduct fire and emergency evacuation drills in accordance with the Virginia Statewide Fire Prevention Code (13 VAC 5-51). EVIDENCE: 1. Staff # 14 stated the last fire/emergency drill was conducted on 01/24/2023. 2. There was not a fire/emergency drill conducted for February 2023 or March 2023.
Plan of Correction:	ED, BOM, and/or other designated person in charge will complete monthly fire and emergency evacuation drills in accordance with the Virginia Statewide Fire Prevention Code (13 VAC 5-51). Fire and Emergency drills will be documented monthly to support compliance. [sic]
Standard #:	22VAC40-73-980-A
Description:	Based on observations made during the tour of the building, the facility failed to ensure that all required items were included in the first aid kit. EVIDENCE: 1. Triangular bandages were not observed by the LI to be in the first aid kit. 2. Per interview with staff # 8, triangular bandages were not available at the facility.
Plan of Correction:	ED, BOM, and/or designated person in charge to audit first aid kit. Triangular bandages obtained and added to first aid kit on 4/12/2023. ED, BOM, and/or RCD will audit first aid kit monthly to ensure compliance. [sic]
Standard #:	22VAC40-90-40-B
Description:	Based on the review of staff files, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for one employee. EVIDENCE: 1. Staff # 10 was hired on 02/14/2023. 2. According to staff #8, staff #10?s background information could not be located on the date of the inspection, 04/04/2023.
Plan of Correction:	ED, BOM, and/or other designated person in charge will inspect/review all new hire files to ensure we obtain a criminal history record report on all new employees prior to the 30th day of employment. [sic]