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: July 26, 2023

Complaint Related: No

Areas Reviewed:

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(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/26/2023 Begin: 10:30am End: 11:30am 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 07/10/2023 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: information not gathered. 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: 1 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 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 #:	22VAC40-73-450-C
Description:	Based on review of resident records, the facility failed to include all needs on the comprehensive ISP (Individualized Service Plan) for one resident as identified on the UAI (Uniform Assessment Instrument). EVIDENCE: 1. Resident #1 was admitted to the safe/secure unit of the facility on 05/30/2023. 2. The UAIs completed on 05/12/2023, 05/30/2023, 06/30/2023, and 07/07/2023 documents resident #1 is disoriented to some spheres, all the time; spheres affected are place and situation. 3. The ISPs dated 06/30/2023 and 07/07/2023 address dementia as a need but do not address disorientation to the spheres affected which are place and situation as needs for resident #1.
Plan of Correction:	1.Resident #1 moved to Valley Rehab on 8/2/2023. 2&3. Review of UAIs/ISPs for each resident are being reviewed to confirm that spheres affected are noted on each document. Date to Be Corrected: Immediately [sic]
Standard #:	22VAC40-73-460-D
Description:	Based on staff interview and resident record review, the facility failed to provide supervision of resident schedules and specialized needs of wandering from the facility. EVIDENCE: 1. Resident #1 was admitted to the safe/secure unit of the facility on 05/30/2023. 2. The assessment of serious cognitive impairment completed by a physician on 05/16/2023 states resident #1 has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and states the individual is unable to recognize danger or protect his own safety and welfare. The physician also listed poor judgement and short-term memory as concerns and documented ?patient will have exit seeking behaviors and will need locked unit?. 3. Progress notes for resident #1 on 06/02/2023 document that resident #1 entered a four-digit key code to exit the safe/secure unit at 4:26 am. Staff were immediately alerted by the sound of a closing door. Resident was observed by facility staff walking down a hall on the assisted living side of the facility. The resident was easily redirected and led back to the safe/secure unit. On 06/02/2023 at 2:27 pm resident #1 used his personal cell phone to look up the phone number to the facility on the internet, he then used his cell phone to call the facility multiple times to request to leave the property. Staff #4 documented ?staff has tried redirecting resident several times without success.? Progress notes document facility staff contacted the helpdesk for the facility?s telephone system on 06/02/2023 to block resident #1?s cell phone number. Per the progress notes, the resident continued to stay near the exit doors in the safe/secure unit, was very hard to redirect, walked around the safe/secure unit and could not be calmed as he was grinding his teeth and clenching his jaws and attempted to take medications from medication aides hands to see if his name was on them. 4. On 06/12/2023 progress notes state resident #1 followed staff around asking for ways to exit the facility and has requested staff speak to facility management to allow him to leave. Resident #1 has used his personal phone to contact family members to let them know he is ready to leave the facility. 5. Progress Notes for 06/30/2023 documented ?Resident participated in morning activities. When resident is not directly engaged, he is pacing the neighborhood, offering associates and other residents money if they will take him to the bowling alley. Resident is difficult to redirect in these instances as he is persistent and very repetitive in conversation.? 6. On 07/06/2023 resident #1 exited the safe/secure unit at 8:11pm and returned to the community at 8:32pm. During an interview with staff #2, she stated that on 07/06/2023 at approximately 8:20 pm she observed resident #1 as he ran out in front of her car approximately 0.7miles from the facility on Route 52. Staff #2 greeted resident #1 on the side of the street and placed resident #1 in her car and immediately called staff #3 who directed staff #2 to transport resident #1 back to the facility. 7. The incident report for 7/10/2023 regarding resident #1 documented that resident #1 ?entered the key code to exit Memory Care?. During an interview on 07/26/2023 with staff #3 she stated resident #1 exited the safe/secure unit at 8:11pm and returned to the community at 8:32pm on 07/06/2023. Per Staff #3, resident #1 was successful at exiting the safe/secure unit because resident #1 memorized the security code to the keypad at the entrance/exit door in the safe/secure unit .Staff #3 also stated during the 07/26/2023 interview that staff have observed resident #3 as he has had his cell phone in his pocket in an attempt to record/capture the finger pattern that staff uses to exit the safe/secure unit.
Plan of Correction:	Training has been completed with staff re: elopement and managing wandering behaviors. On June 5th an Inservice Training was held regarding the use of the keypad when entering and exiting the Memory Care Neighborhood. Staff was trained on being aware of where Resident #1 was when entering the passcode and making sure that the individual was not able to view the numbers that were entered. [sic]