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: May 17, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 2:34 pm End: 3:06pm 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 on 04/07/2023regarding allegations in the area(s) of: resident related care Number of residents present at the facility at the beginning of the inspection: unknown 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: 3 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 #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on the documentation review , the facility failed to implement their medication management plan in regard to one resident?s oxygen use. EVIDENCE: 1. Section 37 of the facility?s medication management plan titled ?Assistance with Oxygen? dated 06/10/2021 #2a states ?if the resident is unable to safely self-administer oxygen, the resident will be assisted by a person qualified according to state regulations. 2. Collateral #1 visited the facility on 03/30/23 and found resident #1?s oxygen tank empty. Resident #1s oxygen saturation measured at 80% when checked by facility staff #1. 3. On 03/31/2023 at 4:05pm collateral #2 found resident #1?s oxygen tank empty. Collateral #2 reported the concern to staff #2 on 03/31/2023 at 4:05pm. 4. On 04/06/2023 at 10:30am collateral #1 entered the facility to visit resident #1; staff #4 accompanied collateral #1 to visit resident #1. Staff #4 confirmed the oxygen tank was again empty and resident #1 was not receiving oxygen. 5. On 04/11/2023 collateral #1 found resident #1?s oxygen tank to be empty. Resident #1?s oxygen saturation was measured at 86% when checked by facility staff. 6. On 05/08/2023 staff #5 stated she found resident #1 with without working oxygen. / 7. On 05/11/2023 staff #3 stated she was the only registered medication aide on duty and had previously checked resident #1?s oxygen tank and it was in working order. Staff #3 stated she is not familiar with how the oxygen machine works
Plan of Correction:	Resident #1 moved out 5/24/2023. Due to concerns with portable oxygen tanks not lasting greater than 1-2 hours, community and NP requested that Hospice assist resident with obtaining a portable concentrator, which she had utilized previously, that would not limit residents mobility and allow for better compliance. Portable concentrator was delivered to community on 5/1/2023. On 5/11/2023, after findings reported by Collateral #1 and Collateral #2, frequent checks were put into place and RMA, DCS, and Director staff were provided training on monitoring battery life of portable concentrator and how to manage a malfunction was provided by Staff #2. Due to concerns with battery life for portable concentrator, as resident is out of apartment for 8+ hours per day, and not wanting to restrict resident?s mobility by plugging into wall, the community purchased an extra battery for resident?s portable concentrator on 5/12/2023. Battery was delivered 5/16/2023. Proof of purchase was provided to LI on 5/17/2023. On 5/16/2023, training was provided by Archie McAlexander, Director of Clinical Services and Maggie Nolen, Business Office Manager, to current staff, to include Directors, on managing Resident #1?s oxygen and portable concentrator. Inservice sheet, along with material covered was provided to LI on 5/17/2023. Subsequent visits by Collateral #1 and Collateral #2 revealed oxygen was in working order and staff able to speak to expectations. Moving forward, it is the responsibility of the Resident Care Director/designee to assure staff are aware of residents ability to manage their oxygen per physician?s order and appropriate interventions will be put into place to assure resident?s needs are being met per regulatory standards. [sic]