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

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: Feb. 6, 2020

Complaint Related: Yes

Areas Reviewed:
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
22VAC40-73 STAFFING AND SUPERVISION
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
22VAC40-73 BUILDING AND GROUNDS

Comments:
The licensing inspector for Commonwealth Senior Living-Christiansburg conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 01/12/2020. Building observations were completed and interviews were conducted with staff and resident's family members. The preponderance of the evidence gathered/reviewed during the investigation does not support the allegations, so the complaint is determined to be not valid. The investigation began at 10:17 am and concluded at 11:28 am on 02/06/2020 and began at 10:00 am and concluded at 10:55 am on 02/21/2020. An exit meeting was held with the administrator of the facility on 02/21/2020 and at that time the findings of the investigation were shared. As a result of this investigation two violations are being cited. Please provide a plan of correction and date to be corrected for each violation cited and return a signed and dated copy of the violation notice to this licensing office within 10 calendar days of receipt (03/21/2020). If you have any questions or concerns please contact your inspector at 276-608-1067. Thank you your assistance and cooperation.

Violations:
Standard #: 22VAC40-73-70-A
Complaint related: No
Description: Based on documentation review, the facility failed to to report within 24 hours to the regional licensing office any major incident that has negatively affected or that threatens the life, health, safety or welfare of two of their residents.
EVIDENCE:
1. Resident #1 had been in Resident #2's room from 6:27 pm until 8:07 pm on 01/04/2020 unsupervised and unobserved. When Resident #1 was found, she was no longer wearing shoes, pants, or briefs. Resident # 1 stated "I wanted to but it didn't work so we couldn't". Resident #1 had to be escorted to her room by facility staff.
2. Staff #1 sent notification to Licensing Inspector on 01/13/2020 at 2:57 pm that stated " We had two memory care residents who unsuccessfully attempted a consensual sexual act.". The incident occurred on 01/04/2020.

Plan of Correction: DISPUTE REQUEST SUBMITTED [sic]

Standard #: 22VAC40-73-930-D
Complaint related: No
Description: Based on documentation review of resident records and facility documentation, the facility failed to document the minimum of every two hour rounds that were made for one resident with an inability to use the signaling device.
EVIDENCE:.
1. Resident #1 has an Individualized Service Plan(ISP) which identifies that she is unable to access the call bell system in her apartment. This need was identified on 05/03/2019 on the ISP. The ISP states "due to physical or serious cognitive impairment resident cannot utilize call bell system; staff will perform every 2 hour checks from time the resident goes to bed to waking up and about and anytime resident is in room resting as needed."
2. Staff # 2 presented the Licensing Inspector with what documentation she had available for two hour rounds from 01/04/2020-02/06/2020. Rounds had been documented as follows:
01/31/2020: "8" and "10"
01/01/2020: nothing was documented for this date
02/02/2020: "8" and "10"; "3":"10" and "5:30"; "7:15" and "9:20"
02/03/2020: "12:10" and "2:18"; "4:20" and "6:27"; "7:10" and "9:08"; "3:05" and "5:00"
02/04/2020: nothing was documented for this date
There was no further documentation available on 02/06/2020.
3. Staff #1 stated the facility had not been keeping consistent documentation of the two hour rounds that are required.
4. Standards requires that this documentation shall be retained for two years.

Plan of Correction: Care team was re-in serviced on how to complete the documentation for the required 2-hour checks for residents that are unable to independently use the signaling device. New documentation has been put in place to ensure consistency of documentation across all shifts. Associates were in-services on how to complete the new form as required by DSS. This completed document will be brought to the morning meeting by the Resident Care Director or designee and reviewed by the Executive Director or designee to ensure ongoing compliance. [sic]

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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