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: Oct. 11, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND

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: 10/11/2023 Begin: 10:35am End: 2:00pm 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: 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: 0 Number of staff records reviewed: 0 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 some, but not all of the allegations area(s) of non-compliance with standard(s) or law were: A violation notice was 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 #:	22VAC40-73-1130-C
Complaint related:	No
Description:	Based on review of security camera footage, the facility failed to ensure at least three staff members were awake and on duty in the memory care unit during the night hours on three separate dates. EVIDENCE: 1. LI, staff #1, and collateral #1 reviewed security camera footage ranging from 10/01/2023-10/10/2023 (night shift) on the memory care unit. 2. Staff #5 appeared to be sleeping in the dining room area the night of 10/02/2023-10/03/2023 from 3:38am-3:38am. 3. Staff #3 appeared to be sleeping near the med cart in a rocking chair with a blanket the night of 10/03/2023-10/04/2023 from 12:16pm-4:43am. 4. Staff #4 appeared to be sleeping in the dining room area the night of 10/10/2023-10/11/2023 from 1:22am-2:56am; moves around then puts head down again from 2:56am-4:59am to sleep again.
Plan of Correction:	Community Assignment sheets have been updated to provide a clear expectation of assignment for each staff, and ability to hold staff accountable. Staff Members that were found sleeping on shift were terminated and are no longer with the company. New and current night shift staff are trained in the expectation of night shift tasks and completion of items. They are aware that sleeping while on duty could lead to immediate termination with reporting to appropriate entities. For the next 60 days, the ED/designee will assure that at least 4 random off shift checks, on 11p-7a shift, are documented and completed to assure continued compliance. Moving forward, the ED/designee will assure that at least 1 off shift check has occurred monthly. [sic]
Standard #:	22VAC40-73-870-B
Complaint related:	No
Description:	Based on observations made during the tour of the building, the facility failed to be free from foul odors. EVIDENCE: 1. When the LI, collateral #1, and staff #2 toured the memory care unit, Room C12 was observed to have a strong urine smell.
Plan of Correction:	Housekeeping checklists will be reviewed with housekeepers to ensure all aspects of cleaning are complete through resident rooms. RCA?s/RMA?s will be trained on the expectation of removing urine-soaked laundry or removing trash from room each round. For the next 60 days, the ED/designee will complete regular, random rounds through community and resident apartments to assure community. [sic]
Standard #:	22VAC40-73-930-D
Complaint related:	No
Description:	Based on review of facility records and staff interviews, the facility failed to document two-hour rounds in the memory care unit. EVIDENCE: 1. On the date of inspection, (10/11/2023) when the LI requested to review all the documented two-hour rounds for the memory care unit for October 2023, staff #1and #2 provided the LI with one page of documentation for 10/03/2023 from 7:00-9:42. According to staff #1 and #2 no additional documentation was available. 2. According to an interview with staff #1, two-hour documented checks for the memory care unit for September 2023 were not completed consistently, she stated, ?I only have hit and miss days from September?.
Plan of Correction:	New and current RMA?s/RCA?s will receive training on completion of the two-hour round documentations to ensure understanding of expectation per regulatory standards. For the next 60 days, the RCD/designee will review when in community and address any documentation concerns at that time. The ED/designee will complete a weekly review of documentation to assure continued compliance. [sic]