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. 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: 09/04/2024 Begin: 10:38am End:4:14pm 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: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 3 + (14 background and sworn disclosures) Number of interviews conducted with residents:2 Number of interviews conducted with staff: 5 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 276-608-1067or by email at crystal.b.mullins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-490-A
Description:	Based on facility records and staff interviews, the facility failed to provide health care oversight at least every six months to those residents who meet assisted living criteria if the facility employs a licensed health care professional who is on site on a full-time basis and is practicing within the scope of his profession. EVIDENCE: 1. The last health care oversight was documented for 7/31/2023-08/02/2023. 2. Collateral #1 and #2 both agreed this was the most recent health care oversight for this facility when the LI asked if there was a more current health care oversight. LI was told the health care oversight was being completed on the date of the inspection (09/04/2024)
Plan of Correction:	The Health Care Oversight was completed on 09/04/2024 during licensing survey. The next HCO will be completed at least every six months for those residents who meet assisted living criteria. [sic]
Standard #:	22VAC40-73-710-E
Description:	Based on resident record and resident interview, the facility failed to have a physician?s order for a non emergency restraint, and failed to be used in accordance with the resident?s service plan. EVIDENCE: 1. Resident# 3 residents in the safe, secure unit of the assisted living facility. 2. Resident #3 was observed to have a fall mat (restraint)in the floor in front of his bed, while the other side of his bed was placed against the wall. Fall mats can be restraints depending on the individual?s functional abilities and capabilities and can be restraining if it keeps resident #3 from approaching his bed with a walker or wheelchair, which he does utilize. 3. Resident #3 did not have a valid physician?s order for the fall mat. 4. When the LI asked Resident #3 what the fall mat was used for his response was: ?to cover the ground when it gets cold?. 5. The fall mat was not listed on resident #3?s current ISP (Individualized Service Plan).
Plan of Correction:	The current fall mat was removed. The fall mat will be replaced with a mat that meets the requirements of the LI. A physician?s order will be obtained from the hospice agency of the resident to place in the resident?s service plan and ISP. [sic]
Standard #:	22VAC40-73-860-I
Description:	Based on observations made during the tour of the facility and staff interviews, the facility failed to store cleaning supplies and other hazardous materials in a locked area. EVIDENCE: 1. Resident Room D-O across from the RCD office was found to be unlocked, unsecured, and unoccupied. LI found Bissell Oxystain Pretreat for carpet and upholstery (22oz) and Rug Doctor OxyDeep carpet cleaner (96 oz). Both bottles read, ?Keep out of the reach of children? on the back labels. 2. The laundry room on D-hall was found to be unlocked and unoccupied and contained a Tide simply all in one laundry detergent (31 oz). The back of the bottle read, ?Keep out of the reach of children?. 3. The furnace room was found to be unlocked and unoccupied. LI located a visible flame under the water heater; there was no shield around the base to protect the flame or to protect items from easily getting to the flame. Approximately three feet from the open flame the LI observed several pieces of cardboard boxes laying in the floor-this could certainly present a fire hazard. 4. According to collaterals #1 and #2 this facility does serve a mixed population.
Plan of Correction:	Resident Room D0 was locked and corrected at time of inspection. The Bissell Oxystain Pretreat for carpet and upholstery (22oz) and Rug Doctor OxyDeep carpet cleaner (96 oz) were removed from the area at the time of inspection. The laundry room was locked with a keypad locking system at the time of inspection to ensure that the room is locked upon exiting the room. The installation/operation manual was reviewed to ensure proper installation of the hot water heater. The unit is installed per manufacture recommendation and does not have a shield that installs around the base. The Deputy State Fire Marshall observed the water heater to be in working order and installed correctly. The cardboard was removed from the furnace room. The room was locked upon exiting. This room will remain locked. [sic]