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: Aug. 10, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 08/10/2023 Begin: 1:10pm End: 1:50pm Documentation obtained at the facility was reviewed at a later date. 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: information not collected The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 41 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: 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 #:	22VAC40-73-680-D
Description:	Based on staff interview, facility self-report, and resident record review, the facility failed to administer medications in accordance with physician?s instructions. EVIDENCE: 1. According to a self-report received by the Licensing Inspector on 07/30/2023, 07/31/2023, and 08/03/2023; a copy of correspondence from the facility to the facility nurse practitioner dated 07/31/2023; and written statements from staff #1 and #2 dated 08/08/2023, residents #1-#28 did not receive any of their prescribed 180(approximately) medications during the facility?s scheduled morning medication pass on 07/29/2023. Residents #29-#41 did not receive any of their prescribed 113 (approximately) medications during the facility?s scheduled morning medication pass on 07/30/2023. 2. Staff #1 submitted a written statement regarding the missed morning medication pass on 07/29/2023. Staff #1 stated, ?I didn?t pass out meds simply because I thought I had more time (I?ve never did morning med pass, not once) and whilst trying to reach my relief I was outside. I then had to be on the phone with my other job?s supervisor and while doing that I wasn?t checking the time like I should have and missed my deadline.? 3. Staff #2 wrote a statement regarding an interview which was held with staff #3. Staff #3 stated she did not pass out meds for the morning medication pass on assisted living on 07/30/2023 because it was too much for one person. According to staff #2, staff #3 did not communicate during her shift that she would be unable to administer the ordered medications on the assisted living side, nor did she request assistance as needed to complete the medication pass. 4. According to resident record review, residents #1-#41 are all rated dependent in medication administration according to their Uniform Assessment Instruments (UAIs) and residents #1-#41?s Individualized Service Plans (ISPs) address medication administration as a service provided by the facility. 5. An interview with Staff #4 and #5 on 08/10/2023 state the facility administers all medications as prescribed and according to the facility medication management plan for residents #1-#41.
Plan of Correction:	Medication times are being reviewed and appropriately adjusted to assure that each medication pass is appropriately managed per regulatory standard. Current RMAs will attend Annual RMA Refresher Training completed by designated trainer and/or pharmacy. Current Licensed Nurses and RMAs will receive education and training on CSL medication management plan. Med Pass Observations will be completed on new and current RMAs by Resident Care Director (RCD)/designee. An audit of each medication cart will be completed by RCD/designee or pharmacy to ensure medication availability. Refresher training of QuickMAR, and community eMAR system will be completed to assure understanding of appropriate documentation after medication administration to each resident as per physician?s order. For the next 30 days, RCD/designee will complete a regular review of MARs to assure medications have been administered and signed for per physician?s order. This will be reviewed with the ED. Any issues identified during medication review will be addressed through re-education, re-training and/or progressive counseling as indicated. [sic]
Standard #:	22VAC40-73-680-E
Description:	Based on facility and staff records and staff interviews, the facility failed to provide medical procedures or treatments ordered by a physician according to his instructions. EVIDENCE: 1. Resident #5 has a physician?s order dated 04/18/2023 to check blood sugar twice daily. According to the July 2023 MAR (Medication Administration Record), blood sugar levels were not checked for resident #5 the morning of 07/29/2023. 2. Resident #6 has a physician?s order dated 07/25/2023 to check blood glucose before meals and at bedtime. According to the July 2023 MAR, on 07/29/2023 at 7:30am, blood glucose was not checked for resident #6. 3. Resident #10 has a physician?s order dated 06/08/2023 to check blood glucose levels every day. On 07/29/2023 at 7:30am, according to the July 2023 MAR, blood glucose levels were not checked for resident #10. 4. Resident #19 has a physician?s order dated 04/18/2023 to check blood glucose every day. According to the July 2023 MAR, on 07/29/2023 at 9:00am, blood glucose levels were not checked for resident #19. 5. Resident #20 has a physician?s order dated 06/27/2023 to drink one can of ensure vanilla twice daily. According to the July 2023 MAR on 07/29/2023, resident #20 did not receive his ensure vanilla at 9:00am. 6. Resident #28 has a physician?s order dated 04/18/2023 to check blood sugar twice daily. On 07/29/2023, according to the July MAR, blood sugar was not checked at 9:00 for resident #28. 7. Resident #33 has a physician?s order dated 04/12/2023 to put T.E.D hose stockings on in the morning and take off at bedtime. According to the July 2023 MAR, the T.E.D hose were not put on resident #33 at 8:00am on 07/30/2023. 8. Resident #40 has a physician?s order dated 04/18/2023 to use Biotene dry mouth oral rinse 10ml, three times daily. According to the July MAR, on 07/30/2023 at 9:00am resident #40 did not receive Biotene oral rinse.
Plan of Correction:	Current RMAs will attend Annual RMA Refresher Training completed by designated trainer and/or pharmacy. Current Licensed Nurses and RMAs will receive education and training on CSL medication management plan. Med Pass Observations will be completed on new and current RMAs by Resident Care Director (RCD)/designee. Training will be provided to RCD and ED on review of eMAR system to assure that blood glucose checks, ted hose, supplements and treatments have been appropriately signed off by registered medication staff as per physician?s order. An audit of each medication cart will be completed by RCD/designee or pharmacy to ensure blood glucose supplies, ted hose, supplements, and treatment availability. For the next 30 days, RCD/designee will complete a regular review of MARs to assure blood glucose checks, ted hose, supplements and treatments are completed and signed as per physician?s order. This will be reviewed with the ED. Any issues identified during medication review will be addressed through re-education, re-training and/or progressive counseling as indicated. [sic]