VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Christiansburg
201 Wheatland Court
Christiansburg, VA 24073
(540) 382-5200

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: April 25, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS

Comments:

Three licensing inspectors conducted a one day license renewal inspection at Commonwealth Senior Living at Christiansburg on 04/25/2019. The inspection started at 10:10 a.m. and concluded at 3:15 p.m.. Resident files were reviewed and the noon medication pass was observed. Medication Administration Records, medications, and physician's orders were reviewed. A tour of the building and grounds was completed and lunch was observed. Residents and collaterals were interviewed. The first aid kit and blood glucose monitoring supplies were observed and reviewed. The facility is licensed to provide care to 84 residents and 76 residents were found to be in care on the day of the inspection. Required postings were observed in the facility. Previous violations were reviewed to determine correction and compliance with standards. Areas of non-compliance are identified on the attached violation notice. An exit meeting was conducted with the administrator on 04/25/2019 and the findings were reviewed. Opportunity was given to find items that were not readily available in the records. As a result of the 04/25/2019 inspection, 16 violations are being cited. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days (05/13/2019) or receipt. If you have any questions or concerns, please feel free to contact your inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-100-A
Description:	Based on observations made during the medication cart audit, the facility failed to implement an infection control program addressing blood glucose monitoring practices that are consistent with Centers for Disease Control and Prevention (CDC) recommendations when assisted blood glucose monitoring is required. EVIDENCE: 1. Resident # 16's name was on the bag containing her blood glucose monitoring equipment but her name was not on her glucometer. 2. Resident # 12?s name was on the bag containing her blood glucose monitoring equipment but her name was not on her glucometer. 3. Resident # 4's name was on the bag containing her blood glucose monitoring equipment but her name was not on her glucometer. 4. Multi-use finger-stick devices were observed in blood glucose monitoring equipment bags labeled with Resident # 4 & # 17?s names. Staff # 2 stated that both residents require assistance with blood glucose monitoring but that she did not use the multi-use finger-stick devices and that single use auto disabling devices were available for all residents receiving assistance with blood sugar monitoring.
Plan of Correction:	The community was found to fail at implementation of an infection control program addressing blood glucose monitoring practices that are consistent with Centers for Disease Control and Prevention recommendations when assisted blood glucose monitoring is required. Resident #16, #12, and #4 blood glucose monitoring equipment has been labeled with the resident?s name. Resident #4 and #17-While not in use the multi-use finger stick devices have been disposed of and will not be allowed on the carts. RCD or appointed designee will conduct cart audits weekly to ensure compliance. [sic]
Standard #:	22VAC40-73-220-A
Description:	Based on documentation review and private duty personnel interviews, the facility failed to meet all requirements for private duty personnel providing care to one resident in the facility. EVIDENCE: 1. Private duty staff # 1 is employed by a licensed home care organization providing care for Resident # 14. 2. During an interview Private duty staff # 1 reported that she assisted with feeding and transferring for resident # 14. 3. The care needs of feeding and transferring were not addressed as being provided by private duty personnel on resident # 14?s individualized Service Plan. 4. Staff # 1 reported in the exit interview that she was unaware of Private duty staff # 1 providing for any care needs.
Plan of Correction:	The community failed to meet all requirements for private duty personnel providing care to one resident in the community. Private duty staff #1 is employed by a licensed home care organization providing care for Resident #14. Private duty staff reported to not be a companion rather to assist resident with feeding and transferring. The care needs were not addressed as being provided by private duty personnel on resident #14 Individualized Service Plan. When ED learned on 4/22/19 that the POA for resident #14 had obtained outside care for loved one the ED met with the POA and reviewed the Residence and Care Agreement and resigned Appendix C (Private Duty Attendants) along with having POA sign the Private Sitter companion packet. The ED along with the POA immediately contacted the Private Duty?s employer and explained the documentation needed to support the continued care. After multiple attempts to obtain the documentation it was received during the inspection. The ED and RCD will review the appropriate steps to each POA at contract signing and at care plan meetings. Private Duty Staff will not be allowed to provide services in the Community until all required documentation has been received and reviewed for compliance. [sic]
Standard #:	22VAC40-73-310-H
Description:	Based on documentation review and staff interviews, the facility failed to comply with 63.2-1805 D of the Code of Virginia when the facility admitted one resident that had a prohibited condition. EVIDENCE: 1. Resident # 14 was admitted to the facility on 02/12/2019. Her physical examination form dated 02/08/2019 says that she had an unstageable wound to the sacrum. The same physical says that she has a stage III or IV pressure ulcer. The wounds were checked as healing but there was no clarification on if the wounds were a stage III or IV. 2. Staff # 3 is a Licensed Practical Nurse (LPN) and she reported that the wounds are not healing and that Resident # 14 is dying. 3. Resident # 14?s physical dated 02/08/2019 says that her diagnosis is Atrial Fibrillation; High Blood Pressure; Cardio Obstructive Pulmonary Disorder; Severe Calor Malnutrition; Bipolar Disorder; Lytic lesions or tumors on ribs and vertebra. This same physical exam form states that she will be under the care of Hospice. 4. Staff # 1 reported that Resident # 14 has Bone Cancer and was placed on Hospice the same day 02/12/2019 that she was admitted to the facility. 5. Nursing and administrative staff #?s 1 (LPN), 3 (LPN), 4 (LPN & facility administrator), and 5 agreed that an unstageable wound is at least a stage III or IV and often has exposed bone structure with eschar tissue. 6. Resident # 14 was admitted to the facility with a prohibitive condition of an unstageable wound to the sacrum
Plan of Correction:	The community failed to comply with 62.2-1805D of the Code of Virginia when the community admitted one resident that had a prohibited condition. The RCD and ED will approve History and Physicals together to ensure that the documentation from the physician is clear and obtain clarification where necessary. Upon doing so the ED and RSD will prevent an admission with a prohibited condition. Resident passed away 5/1/19. [sic]
Standard #:	22VAC40-73-380-A
Description:	Based on review of resident records, the facility failed to ensure that all personal and social data was obtained prior to or at the time of the admission for a resident. EVIDENCE: 1. Resident #4 was admitted to the facility on 03/25/2019. 2. The Personal Data form for Resident #4 was incomplete. The form was missing information regarding the resident's previous mental health/mental retardation services, substance abuse history if applicable, dentist, clergyman/place of worship, local department of social services, insurance numbers and funeral home.
Plan of Correction:	The community failed to ensure that all personal and social data was obtained prior to or at the time of the admission for a resident. Resident #4 did not have a previous mental health/retardation services, or substance abuse history the family left the spaces blank on the data form. The clergyman/place of worship, local department of social services, funeral home funeral home did not apply and the family left the line blank. This form was corrected with family the day after inspection. The ED along with the Business Manager will audit all new business files at time of contract signing to ensure all documentation is complete. [sic]
Standard #:	22VAC40-73-410-A
Description:	Based on record review, the facility failed to file orientation information in the resident record. EVIDENCE: 1. The record for Residents #3,4, and 5 did not contain acknowledgement that the resident received the required orientation upon admission. 2. It could not be determined if Residents #3, 4, and 5 received orientation upon entry into the community.
Plan of Correction:	The community failed to ensure that the records for resident?s #3, #4, and #5 contained acknowledgement that the resident received the required orientation upon admission. It could not be determined if resident?s #3, #4, and #5 received the required orientation upon admission. The above resident orientations have been completed and placed in resident record. ED, RCD, or designee will ensure that orientation is completed on the day of admission and places in resident record. [sic]
Standard #:	22VAC40-73-450-C
Description:	Based upon review of resident records, the facility failed to have the comprehensive individualized service plan (ISP)completed within 30 days after admission. EVIDENCE: 1. Resident #3 was admitted to the community on 03/18/2019. 2. The comprehensive ISP was dated 04/20/2019, this was not in the resident file, but recorded on their electronic system. 3. The resident has a DNR dated 03/19/2019. This was not included on the ISP. 4. Resident #3 had a preliminary ISP dated for 03/18/2019, and a DNR dated 03/19/2019. On the preliminary ISP sated he was a "FULL CODE" and says "will not receive life saving CPR attention as directed by signed DNR instructions. Yellow DNR form will accompany at all times". This is conflicting information.
Plan of Correction:	The community failed to have the comprehensive individualized service plan completed within 30 days after admission. The ISP for resident #3 was LOA on 4/18/19 The ISP was updated on 4/20/19 however had not been signed by the POA. The DNR was obtained and dated for 3/19/19. The Preliminary ISP status was not updated with Yes or No to indicated Full Code or DNR. The conflicting information was corrected during the visit. The ISP was signed by the POA on 5/2/19. [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on observations made during a medication cart audit, the facility failed to implement a medication management plan to include a proper medication disposal plan. EVIDENCE: 1. A bubble medication pack containing a ? mg tablet of Coumadin was observed in a section of the medication cart assigned to Resident # 16. The section was not a bin and the medications was under the divider between the two sections. 2. The bubble containing the ? mg Coumadin had no resident name on it and no directions for administering the medication. 3. A package containing a Coumadin 1 mg tablet with a dispense date of April 3 was observed in the medication cart in Resident # 14?s section. According to Medication Administration Record (MAR) documentation Coumadin 1 mg was discontinued on April 11, 2019. According to this same MAR Resident # 14 no longer receives Coumadin.
Plan of Correction:	The community failed to implement a medication management plan to include proper medication disposal plan. The loose medication on the cart belonging to resident #16, the bubble pack containing the un-labeled Coumadin was removed, and all discontinued medication belonging to resident #14 was immediately disposed of during inspection. The Registered Medication aids are being in-serviced medication management and disposal. The in service will be complete by 5/14/19. The RCD or designee will continue to conduct weekly cart audits. [sic]
Standard #:	22VAC40-73-650-E
Description:	Based on documentation review, the facility failed to maintain signed written physician?s orders or a dated notation of the physician?s oral order in chronological order in one resident record in the sample of two. EVIDENCE: 1. Resident # 14?s physician?s oral order for Albuterol dated 04/07/2019 was being maintained in a pending file along with other resident?s medication pending orders, not in her record. 2. Resident # 14?s physician order to discontinue Zithromax, and to administer Zoloft were in a thinned file not the resident?s record. Oral orders for Oxycodone and Ativan were being maintained in a pending file (along with other resident?s medication orders) and not in Resident # 14?s record. There was no notation of the oral Oxycodone or Ativan orders in Resident # 14?s record.
Plan of Correction:	The community failed to maintain signed written physician?s orders or a dated notation of the physician?s orders or a dated notation of the physician?s oral order in chronological order in one resident record. Resident #14 had a physician?s order for Albuterol dated 4/7/19 was maintained in a pending file and not in resident record. RCD or designee will maintain new orders in resident records within 24 business hours of taking verbal order. RCD or designee will maintain all active orders in resident charts in chronological order. RCD or designee will audit charts ongoing until complete. [sic]
Standard #:	22VAC40-73-680-B
Description:	Based on observations made during a medication cart audit, the facility failed to maintain all medications in a pharmacy issued container with the direction label attached. EVIDENCE: 1. Resident # 16?s blood glucose monitoring bag in the medication cart was observed to contain two Humalog Insulin pins with no pharmacy direction label attached. 2. Resident # 4?s pharmacy issued Atrovastin was observed to have the label torn off, of the bottle laying in the bottom of the medication cart drawer.
Plan of Correction:	The community failed to ensure that all medications were maintained in a pharmacy issued container with the direction label attached. Resident #16 Humalog pens were updated with pharmacy directions post inspection on 4/25/19. RCD has reached out to pharmacy to have this concern corrected to prevent a repeat violation. The label for resident #4 Atorvostatin was replaced, post inspection on 4/25/19. RCD or designee will continue cart audits on a weekly basis. [sic]
Standard #:	22VAC40-73-680-G
Description:	Based on observations made during a medication cart audit, the facility failed to maintain all over the counter medications labeled with the resident?s name. EVIDENCE: 1. Arthritis Pain Relief; Cira Med; Bayer Aspirin; Tylenol; and Liquid Adult Pain Reliever (Acetaminophen) were observed in the medication cart and no resident name or pharmacy issued label were on them. 2. Staff # 2 hand labeled the above medications with a resident name during the inspection.
Plan of Correction:	The community failed to maintain all over the counter medication labeled with the resident?s name. The medications were labeled and corrected by staff #2 during inspection. Registered Medication aids will be in serviced on Medication Management plan and RSD or designee will conduct weekly cart audits. RCD will in-service medication aids. In service will be complete by 5/14/19. [sic]
Standard #:	22VAC40-73-840-B
Description:	Based on observations and documentation review, the facility failed to maintain documentation of examinations and immunizations for one pet living in the facility. EVIDENCE: 1. Resident # 15 was observed throughout the inspection, walking pet # 1 throughout the facility. 2. Pet # 1's examination and immunization records were not maintained at the facility. However, the facility obtained the records during the inspection via fax.
Plan of Correction:	The community failed to maintain documentation of examinations and immunization for one pet living in the community. The documentation for the pet for resident #16 was obtained during visit. ED and BOM will ensure the receipt of vet records are obtain prior to admission. [sic]
Standard #:	22VAC40-73-860-G
Description:	Based on observations made while measuring water temperatures, the facility failed to maintain water temperatures between 105 F and 120 F. EVIDENCE: 1. The water temperature in the women's rest room located next to the conference room on the second floor measured at 123.5.
Plan of Correction:	The community failed to maintain water temperatures between 105F and 120F. The water temperature in the women?s restroom located next to the conference room on the second floor measured at 123.5 F. Maintenance Director has addressed and water temperature to corrected 118F. Water temperatures will be monitored regularly to maintain compliance. [sic]
Standard #:	22VAC40-73-860-I
Description:	Based on observations made during the morning tour of the building, the facility failed to maintain all cleaning supplies and hazardous materials in a locked area. EVIDENCE: 1. Clorox wipes were observed in the unlocked buffet cabinet in the resident dining room. 2. A carpenters bag of tools containing an electric drill, plyers, and screwdrivers were observed in the unlocked maintenance closet under the stairs near the dining room on the first floor.
Plan of Correction:	The community failed to maintain all cleaning supplies and hazardous materials in a locked area. The Clorox wipes in the unlocked buffet were secured on 4/25/19 post inspection. The Maintenance Director was working in the area to patch a hole for fire safety. He did acknowledge leaving his tools unlocked while leaving the area to obtain another tool. The Maintenance Director will ensure that tools are not left unsecured at any time. [sic]
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during the afternoon tour of the building, the facility failed to maintain all equipment clean. EVIDENCE: 1. Two large chest style freezers were observed in the basement pool area. The freezers were turned off and unlocked and the bottoms of both freezers were covered with a large amount of what appeared to be black mold.
Plan of Correction:	The community failed to maintain all equipment clean. Two large chest style freezers were observed in the basement pool area. The freezers were turned off and unlocked and the bottom of both freezers were covered with a large amount of what appeared to be black mold. The freezers were in use during a time while we had permanent freezers repaired. The freezers should have been cleaned and locked once the food was returned to the kitchen built in freezers. The freezers were cleaned and removed from the community to off-site storage. [sic]
Standard #:	22VAC40-73-880-B
Description:	Based on observations and an interview with a resident, the facility failed to ensure that all heating supplied is from a central heating plant or an electrical heating system in accordance with the Virginia Statewide Building Code. EVIDENCE: 1. Resident # 16 in room # 406 has a space heater supplying supplemental heat to her room. 2. Resident # 16 stated that the heat in her room was not adequate and she had to have a heater in her room to keep warm. 3. This floor standing space heater was in addition to a floor standing air conditioning unit and was not confused with the air conditioning unit.
Plan of Correction:	The community failed to ensure that all heating supplied is from a central heating plant or an electrical heating system in accordance with the Virginia Statewide Building code. The portable heater has been removed from Resident #16?s suite. [sic]
Standard #:	22VAC40-73-920-C
Description:	Based on observations made during the morning tour of the building, the facility failed to maintain all bathrooms in a manner that ensured ventilation to the outside in order to eliminate foul odors. EVIDENCE: 1. The overhead vent fan in the common bathroom beside the director of nursing?s office was observed to be inoperable. When the switch was placed in the on position, the vent fan did not come on.
Plan of Correction:	The community failed to maintain all equipment in bathrooms in a manner that ensured ventilation to the outside in order to eliminate foul odors. The overhead vent fan in the common bathroom beside the director of nursing?s office was observed to be inoperable. The fan has been replaced and is now in operating order. [sic]