VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Hillsville
100 Kyle Drive
Hillsville, VA 24343
(276) 728-5333

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: May 17, 2023

Complaint Related: Yes

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

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/17/2023 Begin: 11:40am End: 12:30:26pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing regarding allegations in the area(s) of: resident related issues. 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 staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint 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 #:	22VAC40-73-470-F
Complaint related:	Yes
Description:	Based on documentation review and interview with the administrator, the facility failed to notify the next of kin when a resident suffered serious injury or illness, or there is reason to suspect that such has occurred. EVIDENCE: 1. Staff #1 confirms Resident #1 was involved in a potentially harmful incident with an outside hospice agency staff person on 01/11/2023. 2. Staff #1 stated she did not contact Resident #1?s next of kin; she was under the impression the outside hospice agency had notified the next kin.
Plan of Correction:	The Community will notify the next of kin, legal representative, designated contact person, or, if applicable, any responsible social agency of any incident of a resident whether it results in injury. The resident's record shall include documentation of the notification, including date, time, caller, and person or agency notified. Date to Be Corrected: Immediately [sic]