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: April 2, 2024 , April 3, 2024 and April 4, 2024

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: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/02/2024 (10:20am-2:30pm); 04/03/2024 (10:40am-2:20am) and 04/04/2024 (10:40am-1:00pm) 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: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed: 4 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 6 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 #:	22VAC40-73-100-C-1
Description:	Based on observations made during the noon medication pass, the facility failed to follow their procedures of infection prevention measures. EVIDENCE: 1. Staff #1 did not place a protective barrier between the glucometer and the surface the glucometer was resting on (resident side table) during the noon medication pass on 04/02/2024 for resident #9
Plan of Correction:	Training to be provided to new and current RMA staff regarding infection control practices during medication administration. Resident Care Director, Assistant Resident Care Director or designee will conduct med pass observations, with focus on infection control measures, on RMA staff by 5/18/2024 and at least every 6 months and as needed ongoing. [sic]
Standard #:	22VAC40-73-320-A
Description:	Based on review of resident records, the facility failed to ensure the physical exam by an independent physician within 30 days preceding admission to the facility included all required elements. EVIDENCE 1. Resident #6 was admitted to the facility on 07/10/2021; the required physical examination was completed on 07/06/2021. Penicillin and Celebrex were listed as allergies, but no reactions were documented. 2. Resident #3 was admitted to the facility on 03/15/2023; the required physical examination was completed on 02/15/2023. Ace Inhibitors, Cipro, Levaquin and Protonix were all listed as allergies but there were no reactions documented.
Plan of Correction:	Resident Care Director and Assistant Resident Care Director have contacted physicians for both Residents to obtain clarification on reactions to current allergies. Moving forward, prior to admission, the Executive Director, RCD, or designee will review the Report of Physical Examination to assure current allergies have appropriate reactions listed; if not, clarification will be obtained. [sic]
Standard #:	22VAC40-73-350-B
Description:	Based on resident record review, the facility failed to ascertain, prior to admission, whether one resident in the sample is or is not a registered sex offender. EVIDENCE: 1. Resident #5 was admitted to the facility on 03/11/024. On the final date of the inspection (04/04/2024) the LI could not locate the sex offender check for resident #5. 2. During the exit interview the LI and staff #5 looked in the file a second time for the document, again, it was not located.
Plan of Correction:	Sex offender screening for Resident 5 was completed on 4/5/24 ED or designee will ensure by use of CSL admission check list that new Residents have sex offender screening prior to admission. BOM will audit current residents files; any files observed to not include sex offender screening, immediate screening will be obtained. [sic]
Standard #:	22VAC40-73-450-C
Description:	Based on review of resident records, the facility failed to include a written description of who will provide services and when and where the services will be provided on the ISP (Individual Service Plan) for two residents. EVIDENCE: 1. Resident #6 has an ISP completed on 03/18/2024 with 20 identified needs. The sections ?Persons who will provide services? and ?When and where services will be provided? have been left blank on all 20 of the identified needs. 2. Resident #2 has an ISP completed on 03/04/2024 with 27 identified needs. The sections ?Person who will provide services? and ?When and where services will be provided? have been left blank on all the 27 identified needs. 3. Resident #3 has an ISP completed on 12/18/2023 with 22 identified needs. The sections ?Person who will provide services? and ?When and where services will be provided? have been left blank on all the 22 identified needs.
Plan of Correction:	ISP?s for Residents 6, 2 & 3 have been updated to include missing items. Resident Care Director, Assistant Resident Care Director, or designee will conduct audit of current resident?s ISP?s to ensure completion of the who when and where services will be provided. For the next 60 days, ED will review ISP?s to assure completion per regulatory standards. [sic]
Standard #:	22VAC40-73-550-G
Description:	Based on review of resident records, the facility failed to maintain evidence of the annual review of resident rights for one resident. EVIDENCE: 1. Resident #8 was admitted to the facility on 03/25/2021. There was no evidence of the annual review of resident rights for the 2023 or 2024 year.
Plan of Correction:	Resident 8 will sign current year resident rights acknowledgement. Residents will sign RR at move-in and a review will be completed/signed for at least annually and as needed. [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on observations made during the medication cart audits, the facility failed to implement their medication management plan regarding their method to ensure accurate counts of all controlled substances when assigned medication administration staff changes. EVIDENCE: 1. The ?controlled substance change of shift log? for the safe/secure unit was not documented by the ?on? staff on 04/04/2024 for the night/day shift; the ?off? staff on 04/01/2024 for the day/evening shift; and the ?on? staff on 04/04/2023 for the night/day shift.
Plan of Correction:	Training to be provided to new and current RMA staff regarding medication management plan and requirement of completion of controlled substance change of shift log. For the next 30 days the RCD, ARCD, or designee will conduct daily reviews of Controlled Substance Shift to Shift Log to assure appropriate documentation. Moving forward, these logs will be reviewed for appropriate documentation at least weekly. [sic]
Standard #:	22VAC40-73-680-K
Description:	Based on review or resident MARs (Medication Administration Records) and physician orders, the facility failed to obtain specifics of symptoms, dosage, time frames, and directions as to what to do if the symptoms persist when PRN (as needed) medication is administered by a medication aide to a resident that is not capable of determining whether the medication is needed. EVIDENCE: 1. Resident #12 has a physician?s order dated 01/09/2024 for the following PRN medications: Lorazepam, 2mg, crush one tablet and mix with tiny amount of water-place paste in cheek, may give up to four doses for seizure activity only (control); Lorazepam 2mg, 0.25mL by mouth every four hours as needed for anxiety; and Morphine 20mg, take the contents of one prefilled syringe by mouth every two hours as needed for pain and shortness of breath. 2. Resident #12 resides in the safe/secure unit at this facility and was not able to respond to LI or the medication aide during the noon medication pass. 3. Per an interview with Staff #6, resident #12 is not capable of asking for the above-menioned medications. 4. According to the MAR for resident #12, none of the above-mentioned medications have been administered in March or April 2024.
Plan of Correction:	Resident Care Director/ Assistant Resident Care Director have contacted MD for Resident 12 to obtain clarification. Resident Care Director & Assistant Resident Care Director will audit PRN medications on current and new residents to ensure documentation is received per the Documentation of Physician or Prescribers Oral Order for PRN Medications. PRN medications observed to be missing appropriate information, per regulatory guidelines, will be updated as appropriate. RCD, ARCD or designee will review new PRN orders to ensure accuracy. [sic]