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 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/04/2023 Begin: 10:15am End: 10:45pm, 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 on 03/22/2023 regarding allegations in the area(s) of: medication administration 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 Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on documentation, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected the health, safety, or welfare of any resident. EVIDENCE: 1. Resident #1 was sent out to the hospital for treatment on 02/19/2023 and returned to the facility on 02/24/2023. Upon resident #1?s return, the facility did not administer any of resident #1?s medications listed on the hospital discharge orders dated 02/24/2023. 2. The facility did not notify the regional licensing office until 03/22/2023.
Plan of Correction:	ED/designee will ensure that within 24 hours of a major incident that negatively affects the health, safety, or welfare of any resident is appropriately reported to the regional licensing office [sic]
Standard #:	22VAC40-73-70-C
Description:	Based on documentation, the facility failed to report to the regional licensing office within seven days any major incident that has negatively affected the health, safety, or welfare of any resident. EVIDENCE: 1. Resident #1 was sent out to the hospital for treatment on 02/19/2023 and returned to the facility on 02/24/2023. Upon resident #1?s return, the facility did not administer any of resident #1?s medications listed on the hospital discharge orders dated 02/24/2023. 2. The facility did not notify the regional licensing office until 03/22/2023.
Plan of Correction:	ED/designee will assure that appropriate follow-up to any major incident that has negatively affected the health, safety, or welfare of a resident is provided to the regional licensing office. [sic]
Standard #:	22VAC40-73-650-F
Description:	Based on staff interview and resident record review, the facility failed to administer medications in accordance with the physician?s orders obtained upon hospital discharge. EVIDENCE: 1. According to an interview with staff #1, resident #1 is dependent in medication administration. 2. Resident #1 was discharged from the hospital and back to the facility on 02/24/2023 at approximately 3:30pm and was not administered any medications listed on the hospital discharge orders dated 02/24/2023 by the facility. 3. According to a self-report, the February 2023 MAR, and an interview with staff #1, resident #1 did not receive any routine evening or nighttime medications on 02/24/2023. Those medications included: Albuterol 0.083%; Carvedilol 12.5mg; Divalproex Sod ER 500mg; Dofetilide 250mcg; Ferrous Sulfate 325mg; Fluticas Prop-Salm; Mealatonin 5mg; Montelukast 10mg; Pantoprazole 40mg; Quetiapine 25mg; Sucralfate 1gm; Vitamin C 500mg; Barrier Cream. 4. Resident #1 was discharged from the hospital on 02/24/2023 with a new medication order for Diltiazem CD/ER 120mg capsule, take one by mouth every day. According to the February MAR, resident #1 did not receive this medication on 02/25/2023, 02/26/2023, or 02/27/2023. 5. Resident #1 was discharged from the hospital on 02/24/2023 with a change to an existing medication order; Carvedilol 12.5mg twice daily was changed to 6.5mg twice daily. Resident #1 continued to receive the 12.5mg dose at 9am and 7pm on 02/25/2023 and 02/26/2023, and 9am on 02/27/2023. Resident #1 did not receive any Carvedilol according to the MAR for 7pm on 02/27/2023. 6. Resident #1 was discharged from the hospital on 02/24/2023 with a discharge order for Loperamide 2mg, take two capsules by mouth every day for chronic diarrhea. According to the MAR, resident #1 continued to receive this medication on 02/25/2023, 02/26/2023, and 02/27/2023.
Plan of Correction:	At time of report to regional licensing office, Resident #1 was receiving appropriate medications per physician order. Medication staff have received refresher training provided by Southern Pharmacy on 4/27/2022. RCD/designee will assure that when a resident is newly admitted or returns from hospital/rehab, updated medication list will be faxed to the pharmacy to assure medications are available for administration per medication plan and regulatory standards. Concerns with obtaining required orders and/or medications will be reported to the supervisor for appropriate follow-up.[sic]