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: Feb. 21, 2020

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

Two licensing inspectors conducted a one day mandated license renewal inspection at Commonwealth Senior Living-Christiansburg. The inspection started at 10:00 am and concluded at 3:50 pm. A sample of resident and staff files were reviewed. Required postings were checked. The noon medication pass was observed and medication cart audits were conducted. Residents and collaterals were interviewed. Lunch was observed being served. Activities were observed along with staff interactions with residents. An exit meeting was conducted with the administrator and other key staff on 02/21/2020 and at that time the opportunity was given to find items that were not readily available in the files. As a result of this renewal inspection, 11 violations are being cited. Please develop a plan of correction for each of the violations cited along with a date of correction and return a singed and dated copy back to the licensing office within ten calendar days (03/09/2020) of receipt. If you have any questions or concerns please contact your inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on observations made during the review of resident records, the facility failed to ensure that each person shall have a physical examination completed within 30 days prior to admission by an independent physician and shall include the required information. EVIDENCE 1. Resident #6, #7, #8 and #9 all had allergies listed on their physical examinations. There were no reactions listed for the allergies.
Plan of Correction:	Documentation was obtained from the physician for resident #6,6, 8 and 9 detailing the reactions to the identified allergens. All other admission history and physicals received after 02/01/2018 were checked to ensure compliance. Resident Care Director will check all history and physical forms prior to admission to ensure required documentation is complete. Executive Director will audit 5 history and physical forms per month to ensure ongoing compliance. [sic]
Standard #:	22VAC40-73-410-A
Description:	Based on review of resident records, the facility failed to ensure that two newly admitted residents had signed and dated documentation to show they had received orientation to the facility. EVIDENCE: 1. Residents # 7 and # 8 were both admitted to the facility on 11/29/2018. There was no documentation available in their files to show they had signed and dated the required resident orientation.
Plan of Correction:	Documentation of orientation was obtained for Resident #7 and 8. Orientation will be completed on the day of move in tot he community. Executive Director or designee will ensure that every new resident and legal representative will be given an orientation tot he community which includes emergency response procedures, mealtimes, use of the call system, and other required orientation components. The acknowledgement of the completed orientation will be kept in the resident's Business Office file. All other resident files were reviewed to ensure compliance. Business Office Manager will review the Business File within 24 hours of admission to ensure continued compliance.
Standard #:	22VAC40-73-460-D
Description:	Based on interviews with residents, the facility failed to provide attention to specialized needs of two residents. EVIDENCE: 1. Resident # 5 stated she has to use her wheelchair to get down to the dining room area and to the library for activities. Both the dining room and the library are located on the first floor of the facility. Resident # 5's room is on the second floor. Resident # 5 stated she has been diagnosed with De Quervain?s Tenosynovitis which is inflammation of the thumb tendons due to repetitive motion. She stated this was due to her wheeling herself in her wheelchair. She has an antibiotic ointment applied to the area four times a day for swelling and inflammation and she also applies ice to her wrist and thumb. She stated she now has to have someone wheel her downstairs for meals and for activities. She stated that staff are good to come and get her for meals and activities, however; she has to wait at least 30 minutes to find someone to bring her back to her room after meals and activities. She stated that the kitchen staff sometimes wheel her back to her room because no other staff member is available to take her. 2. Resident # 2?s room is located on the first floor of the facility. He stated he needs assistance with wheeling to the dining room area and to the library for activities. He stated that there is no issue being taken to meals or activities but he has to wait sometimes afterwards at least 30 minutes for a staff member to take him back to his room. 3. Staff #6 and #7 both agree that Resident #2 and #5 both need assistance and they are sometimes forced to wait and suggested that the staff available during these times take these residents to their room before addressing other tasks.
Plan of Correction:	A meeting was held with resident #2 and #5 to review the concerns and discuss individual care needs. The needs and desires were implemented as per the resident's request. The community will provide attention to specialized needs of residents. Resident #5 and #2 will be wheeled by staff to desired location upon completion of meals, programming, and other activities. Executive Director, Resident Care Director, Assistance Resident Care Director, or designee will ensure that individual needs and desires are met. [sic]
Standard #:	22VAC40-73-550-F
Description:	Based on observations made during the morning tour of the building, the facility failed to post the name and telephone number of the appropriate regional licensing administrator for the department. EVIDENCE: 1. On the bulletin board downstairs located across from the entrance into memory care the rights and responsibilities of the residents did not have the appropriate regional licensing administrator or phone number posted on the last page of the resident rights information sheet.
Plan of Correction:	The resident rights posting was updated with the current name and telephone of the licensing administrator. Executive Director or designee will round the community a minimum of 2 times per day and will ensure that postings are correct. [sic]
Standard #:	22VAC40-73-560-F
Description:	Based on observations made during the medication pass, the facility failed to ensure all records are treated confidentiality. EVIDENCE: 1.Staff #1 was the medication aide passing medications on the memory care unit and at approximately 11:25 am staff #1 left the medication cart to assist a resident with a fall. Staff #1 left the computer on top of the med cart open with medication administration records for residents displayed and unattended for approximately 5 minutes.
Plan of Correction:	The documents were not protected while the RMA was assisting with a medical emergency. Executive Director or designee to re-educate current staff on the requirement to keep confidential documents protected. Executive Director, Resident Care Director, and Assistant Resident Care Director will monitor on rounds to ensure continued compliance and take corrective action immediately if identified as unsecured. [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on observations made during the medication cart audits, the facility failed to follow a medication management plan. EVIDENCE: 1. The licensing inspector observed a Novolog pen belonging to Resident # 1 on the medication cart located in Memory Care that did not have an open date or expiration dated written on it. Novolog expires 28 days after opening. 2. The licensing inspector observed Permethrincre 5% started on 1/3/2019 to be applied to scalp for 10 minutes and then re-applied seven days later for lice on the medication cart located in the memory care unit. The treatment was completed on 1/10/2020 for Resident # 2. 3. According to the Medication Administration Record (MAR) for February 2020 Resident #2 is prescribed Calmseptine Ointment 1120 Gm to be applied topically to vaginal are twice daily as needed for dry spots. There was no order available for this resident for this medication. The MAR was not updated accurately to reflect the change or addition of a new order within 24 hours of receipt of the order.
Plan of Correction:	All nurses and RMSs re-educated on the medication management policy and to specifically dispose of discontinued medication, ensure dating of items as required, etc. Executive Director, Resident care Director, or designee will ensure adherence to the medication management policy with annual review and training of all staff. Random monitoring of compliance will be completed a minimum of one time per week by the Executive Director, Resident Care Director, Assistant Resident Care Director, or designee to ensure continued compliance. Executive Director, Resident Care Director, or designee will conduct a random audit of 5 charts per week to confirm that an order is in the chart for every medication to ensure continued compliance. [sic]
Standard #:	22VAC40-73-650-A
Description:	Based on review of resident records and Physician?s orders, the facility failed to ensure no treatment shall be started, changed or discontinued by the facility without a valid order from a physician or other prescriber. EVIDENCE: 1. According to the medication administration record for the month of February 2020 Resident # 2 is prescribed Calmseptine Ointment 1120 Gm to be applied topically to vaginal area twice daily as needed for dry spots. There was no order located in the resident?s file for this treatment.
Plan of Correction:	The ordered was placed in the chart of resident #2. All medication administration orders were checked to ensure that a valid physicians order was present and that the prescribed medications were available in the medication cart to ensure compliance. Licensed Nurse will continue to review all new medication orders in the Electronic Medication Administration Record and compare them to the physician's order and diagnosis prior to approving medicatin for administration and discontinuation orders will continue to be sent to pharmacy to discontinue active medications orders to ensure ongoing compliance. Resident Care Director, Assistant Resident Care Director, or designee will complete monthly cart audit and chart audits to ensure no medication is started or discontinued by facility without a valid order from a physician or prescriber. [sic]
Standard #:	22VAC40-73-650-E
Description:	Based on review of resident records and physician?s orders, the facility failed to ensure orders are organized chronologically in the resident?s record. EVIDENCE: The following orders were not filed chronologically in resident records: 1. Ensure drink 1 can by mouth at lunch for dietary supplement; anti-diarrheal take 2 tablets (4mg) by mouth as needed after loose stool for diarrhea, anti-diarrheal 2 mg tablets take one tablet by mouth as needed after each loose stool thereafter for diarrhea; Lorazepam 0.5 mg take one tablet by mouth every 8 hours as needed prescribed for Resident # 2. 2. Acetaminophen 325 mg tablet take 2 tablets (650mg) by mouth three times daily for pain; Levetiracetam 750 mg tablets take one tablet by mouth twice daily for seizures; Silace Liq 10 MG/ML take 2 teaspoonful (10ML) (100MG) by mouth every day for constipation; Valproic Acid 250 MG/5ML SOL take 2 teaspoonful (10 ML) (500 MG) by mouth three times daily for seizure prevention; Morphine 20MG/ML OS 30 ML take 0.5 ML by mouth every two hours as needed for pain prescribed for Resident # 3. 3. Tobacco may smoke a cigarette after each meal and before be; , Acetaminophen 500 mg take 2 tablets by mouth every 8 hours as needed for pain; Ibuprofen 800 mg take one tablet by mouth every 8 hours as needed for pain; Lidocaine Viscous 2% take 1 tablespoonful (15ml) by mouth every 3 hours as needed for pain prescribed to Resident # 4. 4. These physician's orders were not able to be located in the residents files. These orders were available and were being stored in the "to be filed" section of Staff #6's office.
Plan of Correction:	Documents were filed appropriately in the resident charts for residents # 2, 3, and 4. All other charts were checked to ensure compliance. All active orders will be located in the resident's chart in chronological order within 24 hours of receipt of order. Executive Director, Resident Care Director, or designee will conduct a random audit of 5 charts per week to confirm that an order is in the chart for every medication to ensure continued compliance. [sic]
Standard #:	22VAC40-73-680-K
Description:	Based on observations made during the Medication Administration Record (MAR), the noon medication pass, and physician's orders, the facility failed to obtain a detailed medication order from the resident's physician or other prescriber to include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist. EVIDNECE: 1. Resident # 1 is prescribed Oxycodone 5mg take one tablet by mouth every six hours as needed for pain scale 5-10. The resident's physician or other prescriber did not include what to do if symptoms persist.
Plan of Correction:	A clarification order was obtained from the physician and the medication order was discontinued. All medication administration orders were checked to ensure that all required elements were present int he prescirber order. Licensed Nurse will continue to review all new medication orders in the Electronic Medication Administration Record and compare them to the written physician's order and diagnosis prior to approving the medication for administration and discontinuation orders will continue to be sent tot he pharmacy to discontinue active medication orders to ensure ongoing compliance. Resident Care Director, Assistant Resident Care Director, or designee will complete monthly cart and chart audits to ensure no medication is tarted or discontinued by facility without a valid order from a physician or prescriber. [sic]
Standard #:	22VAC40-73-680-M
Description:	Based on observations made during medication cart audits, not all as needed (PRN) medications were available for one resident in care. EVIDENCE: 1. Resident # 2 is prescribed Anti-Diarrheal 2 mg tablets take one tablet by mouth as needed after each stool thereafter for diarrhea. This medication was not located on the mediation cart located in the Memory Care Unit.
Plan of Correction:	The medication for resdient #2 was received from the pharmacy and placed in the medication cart. All nurses and RMSs were in-serviced on the importance of medications being refilled and present on the medication cart in accordance with the physician orders and Board of Nursing Standard of Practice. Resident Care Director or designee will conduct a random medication cart audit a minimum of once a week to ensure continued compliance. [sic]