VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at South Boston
435 Hamilton Boulevard
South boston, VA 24592
(434) 575-5400

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: Sept. 25, 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 ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/25/2023 9:30am until 4:00pm 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: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 12 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1110-B
Description:	Based on resident record review, the facility failed to ensure that a review of appropriateness of placement in a safe secure unit was completed annually foe residents. EVIDENCE: 1. The record for resident 7, who resides in the facility safe, secure unit, has documentation that the last review of appropriateness of placement in a safe, secure unit was completed on 08/30/2022.
Plan of Correction:	What has been done to correct- Resident 7 assessment was completed for his appropriateness of placement in a safe, secure unit on 10/6/23. How will recurrence be prevented- An audit will be completed on our Sweet Memory residents to ensure yearly assessments are documenting appropriateness of placement in a safe, secure unit. Person responsible- ARCD
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to ensure that individualized service plans (ISPs) were updated at least annually or when a change in resident condition occurred. EVIDENCE: 1. The uniform assessment instrument (UAI) dated 06/04/2023 in the record for resident 5 has documentation that the resident is incontinent of bowel and bladder and requires assistance with wheeling. Interview with staff 4 on the day of inspection verified that the UAI is correct. The ISP dated 06/04/2023 in the record for resident 5 does not identify services to be provided for these assessed needs. 2. The UAI dated 07/09/2023 in the record for resident 7 has documentation that the resident is incontinent of bowel and bladder. Interview with staff 3 on the day of inspection verified that the UAI is correct. The ISP dated 07/09/2023 in the record for resident 7 does not identify services to be provided for these assessed needs.
Plan of Correction:	What has been done to correct- ISP for Resident 5 and Resident 7 has been updated with the correct identified services. How will recurrence be prevented- An audit of all UAI and ISP will be completed to ensure they match and identify services needed by the residents. Person responsible- ED, RCD and ARCD
Standard #:	22VAC40-73-610-D
Description:	Based on resident record review and staff interview, the facility failed to ensure that when a diet is prescribed for a resident by his physician or other prescriber, it shall be prepared and served according to the physician's or other prescriber's orders. EVIDENCE: 1. The record for resident 12 contains documentation that the resident was seen by Collateral 1 on 08/02/2023 due to the resident having difficulty chewing. The resident?s record contains a physician?s order, dated 08/02/2023, for the resident?s diet to be changed to a soft diet. 2. During on-site inspection on 09/25/2023, the posting in the facility?s kitchen indicated that the resident is on a no added salt diet. 3. During an interview with staff person 8, it was expressed to the licensing inspector (LI) that the kitchen was not aware of the resident?s diet being changed to a soft diet per the physician?s order dated 08/02/2023 and that the resident does spit out her food, mostly meats, a lot while eating. Three other dietary staff in the kitchen during the interview with staff person 8 expressed that they were unaware as well of the diet order change for resident 12.
Plan of Correction:	What has been done to correct- dietary staff were notified about Resident 12 diet order change to a soft diet. How will recurrence be prevented- An audit will be completed to ensure dietary department has the correct diet orders for each resident. Person responsible- ED and designee.
Standard #:	22VAC40-73-640-A
Description:	Based on resident record review, resident and staff interview, and facility policy review, the facility failed to ensure to implement its medication management plan in regard to the identification of the medication aide or the person licensed to administer drugs responsible for routinely communicating issues or observations related to medication administration to the prescribing physician or other prescriber. EVIDENCE: 1. The facility?s medication management plan indicates the following in regard to communication of medication related issues or observations to physician in section Med 43 dated 06/10/2021: The resident care director and the resident?s physician will be informed of any medication related issues or observations, the medication aide who becomes aware of any medication related issues or observations will document the issue/observation on the medication aide to medication aide communication log and inform the resident care director, examples of issues or observations include, but are not limited to, refused medications, adverse medication effects, missed medication dosages, medication concerns reported by a resident etc., and the medication aide who observed the issue or observation of concern is responsible for routinely communicating issues or observations related to medication administration to the prescribing physician or other prescriber. 2. The record for resident 11 contains a physician?s order, dated 07/03/2023, for ferrous sulfate 325MG one tablet by mouth daily for iron deficiency. The September 2023 medication administration record (MAR) for the time period of 09/01/2023 through 09/25/2023 for the resident contains documentation that the resident was not administered the aforementioned medication numerous time during this time period. 3. During an interview with resident 11, the resident expressed to the licensing inspector (LI) that she refuses to take the medication anymore because it makes her sick within one hour of taking the medication and has informed medication staff of this. 4. During an interview with staff person 4, the staff person informed the LI that the facility does not have the medication for the resident anymore because the resident has been refusing to take the medication due to it making her sick after taking it. The staff person expressed to the LI during the on-site inspection that the aforementioned information has not been communicated to the resident?s physician to inform him that the resident has not been taking the medication and that the resident wants the medication to be discontinued.
Plan of Correction:	What has been done to correct- Dr. was notified and the ferrous sulfate was discontinued on 9/26/23 for resident 11. How will recurrence be prevented- Staff will be in-service on medication related issues or observations and when to notify the Physician. Person responsible- ED, RCD and ARCD
Standard #:	22VAC40-73-660-B
Description:	Based on observation, resident interview and resident record review, the facility failed to ensure residents may be permitted to keep their own medication in an out-of-sight place in their room if the uniform assessment instrument (UAI) has indicated that the residents are capable of self-administering medication. EVIDENCE: 1. At approximately 9:50 AM during on-site inspection, one licensing inspector (LI) observed a bottle of Tylenol Extra Strength 500 MG tablets on the bedside table in resident 11?s room. 2. The LI interviewed resident 11 and the resident informed the LI that the bottle of Tylenol is her own personal medication and that she has taken some of the Tylenol due to not wanting to have to wait on medication staff to get her Tylenol if she needs it from the facility?s medication cart. 3. The record for the resident does not contain a physician?s order that the resident may have and self-administer the aforementioned Tylenol. 4. The UAI for the resident, dated 06/30/2023, indicates that the resident requires her medication to be administered/monitored by a lay person; registered medication aide (RMA) or an LPN.
Plan of Correction:	What has been done to correct- New order obtained for Tylenol ES 500mg 1 tablet every 4 hours PRN for pain and may keep at bedside for resident 11, she is capable of self-managing her own medications. How will recurrence be prevented- AL room checks will be performed weekly to monitor for over-the-counter medications. Person responsible- ED, RCD and designee
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to ensure that medications were administered in accordance with physician instructions. EVIDENCE: 1. The record for resident 12 contains a physician?s order, dated 03/23/2023, for Donepezil 5MG and Memantine ER 28MG both indicated for a diagnosis of dementia and that this drug regimen is to be continued indefinitely. 2. The September 2023 medication administration record (MAR) for resident 12 did not contain documentation that these medications are being administered per physician instructions. 3. Interview with staff 5 revealed to the licensing inspector (LI) that the medications have not been administered since the 03/23/2023 physician order and that there is no physician?s order discontinuing the medications.
Plan of Correction:	What has been done to correct- MD was notified and a clarification order was written to discontinue Resident 12 Donepezil and Memantine. How will recurrence be prevented- An audit of AL charts will be checked for new orders to ensure carryover to the Physician order sheet. Person responsible- ED, RCD and designee
Standard #:	22VAC40-73-700-2
Description:	Based on observations of the facility physical plant, the facility failed to post a ?No Smoking-Oxygen in Use? sign on any room where oxygen is used. EVIDENCE: 1. At 9:58am on the day of inspection room 209 was noted to have an oxygen concentrator that was turned on and oxygen canisters sitting in the room. A ?No Smoking-Oxygen in Use? sign was not posted on the room.
Plan of Correction:	What has been done to correct- No Smoking-Oxygen in use sign was put on Room 209 at 10am on 9/25/23. How will recurrence be prevented- An Oxygen audit will be conducted to ensure every room that has oxygen has a No smoking-oxygen in use sign on the door. Person responsible- RCD and ARCD.