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: Sept. 20, 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: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/20/2023 Begin: 10:15 am End: 4:50 pm 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: 67 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: 34 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 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 #:	22VAC40-73-640-A
Description:	Based on observations made during the medication cart audit, the facility failed to follow its written plan for medication management, including methods to prevent the use of outdated, damaged, or contaminated medications. EVIDENCE: 1. The LI observed a Tresiba FlexTouch insulin pen in the medication cart for resident # 10. It had been opened and used but there was no open date on the container. 2. Per manufacturer instructions, ?After use, Tresiba may be kept at room temperature or refrigerated for up to 8 weeks? (56 days).
Plan of Correction:	1.The open date was written on the container. All medications will be dated when opened. [sic]
Standard #:	22VAC40-73-650-A
Description:	Based on observations made during a tour of the building and resident record review, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter (OTC), and sample medications. EVIDENCE: 1. The LI observed a bottle of Tums Antacid tablets and a tube of Toothache & Gum Relief Gel on a shelving unit in the bathroom in resident room #B8. LI was unable to find physician or other prescriber orders for these OTC medications in the records for either of the residents of this room. (Resident #11 & #12) 2. The LI observed a tube of Biofreeze pain relief gel sitting on the bathroom sink in resident room #B3. LI was unable to find a physician or other prescriber order for this OTC medication in the record for resident #13.
Plan of Correction:	1. Items were removed from the resident?s room. Residents were reminded that any OTC medications must have orders from physician and kept in medication cart. 2. The item was removed from resident room. Resident was reminded that any OTC medication must have orders from physician and kept in medication cart. [sic]
Standard #:	22VAC40-73-680-M
Description:	Based on a review of resident records and medication cart audit, the facility failed to ensure that medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility. EVIDENCE: 1. The September 2023 Medication Administration Record (MAR) and physician?s orders as of 08/18/2023 for resident # 14 include Hemorrhoidal Cream 51 GM, apply topically twice daily as needed for hemorrhoids. 2. The above referenced medication was not observed by the LI or staff # 2 to be in the B-Hall medication cart on the date of inspection
Plan of Correction:	1. Southern Pharmacy was contacted as to why the medication was never delivered. They stated the medication would be delivered on 10/6/2023. [sic]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the tour of the building, the facility failed to maintain the interior and exterior of all buildings in good repair and kept clean. EVIDENCE: 1. The C-hall in the safe, secure unit from the white chair rail down to the floor is scraped, scratched and the baseboards appeared dusty and scuffed. 2. The furnace intake on C-hall in the safe, secure unit appeared to be rusted and was loose from the wall at the bottom right corner. 3. The door to the kitchen area in the safe, secure unit was scraped, scratched, and had paint missing from the door handle down to the bottom of the door. Paint was found to be missing specifically around the door handle and the door frame/trim. 4. The chair rail in the dining area in the safe, secure unit was observed to be scraped and scratched. 5. The chair rail between room A-11 and A-13 in the safe, secure unit was missing paint, as it appeared to be chipped off. 6. A-11 resident door had deep scratches in the varnish/paint along the bottom 14 inch section of the door. 7. The A-hall on the safe, secure unit was observed to have a furnace filter/intake which was covered in dust and dirt.
Plan of Correction:	1. C Hall chair rail and baseboards to be sanded and repainted. 2. C Hall furnace intake to be replaced and properly secured to the wall. 3. The door to the kitchen area will be sanded and repainted. 4. The chair rail in the dining room will be replaced with new chair rail. 5. The chair rail between A-11 and A-13 will be sanded and repainted. 6. A-11 door will be sanded and repainted. 7. A Hall furnace filter/intake will be cleaned weekly. [sic]
Standard #:	22VAC40-73-870-B
Description:	Based on a tour of the building, the facility failed to ensure all buildings shall be well-ventilated and free from foul, stale, and musty odors. EVIDENCE: 1. LI observed a strong odor resembling urine in resident room #B0. 2. LI observed a strong foul odor in resident room #D5. Staff confirmed this is an ongoing issue in this room.
Plan of Correction:	1. Resident room (B0) was inspected due to a strong odor. No urine or source of smell was located. The room and bathroom were cleaned. Housekeeping to check room daily. 2. Resident room (D5) was inspected. Bedding changed and bathroom cleaned. Housekeeping and staff will clean and inspect the room for odors and source of odors daily. Resident reminded to practice good hygiene. [sic]
Standard #:	22VAC40-73-870-E
Description:	Based on a tour of the building, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. EVIDENCE: 1. Dark spots/stains resembling feces were observed in the toilet bowls in resident rooms #B7, #B3, #B2 and #D3. 2. The toilet seats in rooms #B2 and #D3 appeared soiled with yellow and brown spots/stains. 3. A used washcloth was observed under the shower bench in resident room #B8. 4. Used towels and washcloths were observed in the shower floors in resident rooms #B7, #B3, #B4 and #B2. 5. The nonslip mat in the shower floor in resident room #B3 appeared soiled/stained with several dark spots covering approximately 1/3 of the surface of the mat. 6. The bathmat in front of the toilet in resident room #B2 was soiled with a dark substance appearing to be feces.
Plan of Correction:	1. Toilet bowls were cleaned. Housekeeping to put task on weekly cleaning list and/or as needed for all resident rooms. 2. Toilet seats will be replaced. 3. Washcloth removed. Staff will check the shower area daily to remove used bath linen. 4. Towels and washcloths were removed from shower area. Staff will check the shower area daily to remove used bath linen. 5. Nonslip mat in shower floor will be removed and cleaned or replaced. 6. Bathmat will be washed. Housekeeping to put task on weekly cleaning list and/or as needed. [sic]
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to obtain a criminal record history report on or prior to the 30th day of employment for each employee. EVIDENCE: 1. Staff # date of hire was 04/04/2023. The criminal record check was not completed until 06/20/2023. 2. Staff #20 date of hire was11/08/2022. The criminal record check was not completed until 09/19/2023.
Plan of Correction:	1. Criminal record history reports will be obtained prior to the first day of employment. 2. Criminal record history reports will be obtained prior to the first day of employment. [sic]