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: Jan. 4, 2022

Complaint Related: No

Areas Reviewed:

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

Two licensing inspectors conducted a one day monitoring licensing inspection at Commonwealth Senior Living-Christiansburg. The self-report monitoring inspection began at 4:02pm and concluded at 5:02pm. The licensing inspectors reviewed resident records and requested additional records to follow. An exit meeting was held with the administrator of the facility on 01/04/2022 and again on 02/16/2022. Five violations are being cited as a result of this self-reported monitoring inspection. If you have any questions or concerns please do not hesitate to contact your inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-1110-A
Description:	Based on resident record review, the facility failed to document in writing if a safe, secure environment was an appropriate placement. EVIDENCE: 1. Resident #1 was admitted to the facility?s special care unit on 05/30/2021. In Resident #1?s file the approval for placement in special care unit was signed by Collateral #1, the Power of Attorney for Resident #1, but at the bottom of the form there was no documentation in writing nor a signature on the facility?s behalf to determine and justify the need for Resident #1 to be placed in the special care unit.
Plan of Correction:	Resident #1 no longer resides at the community. All current residents? files will be reviewed to ensure approval for placement in special care unit are signed on behalf community. Upon the resident being admitted to the special care unit the approval for placement will list the approval for justification will be documented with the signature of the Executive Director or Designee. This is the responsibility of the Executive Director or Designee. [sic]
Standard #:	22VAC40-73-1110-D
Description:	Based on resident record review, the facility failed to maintain a review within six months after placement and annually of the appropriateness of continued placement of one resident in the safe, secure environment. EVIDENCE: 1. Resident #1 was admitted to the safe, secure unit on 05/30/2019. A six month review of appropriate placement (November 2019) nor the annual reviews (November 2020 and November 2021) were in writing and retained in Resident #1?s file. 2. Information was not available in Resident #1?s file to indicate that a family member or responsible party, direct care staff who work with the resident or any other licensed health care professionals, the resident?s physician or mental health providers were consulted by the facility in regards to the continued appropriate placement in the safe, secure unit.
Plan of Correction:	All residents residing on the special care neighborhood has been reviewed for appropriateness of placement. Residents will be reviewed within six months after placement and annually for appropriateness of placement. Assistant resident Care Director and Executive Director will ensure residents are reviewed within six months and annually when residing on the special care neighborhood. [sic]
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review, the facility failed to have the ISP (Individualized Service Plan) signed by the resident or his/her legal representative. EVIDENCE: 1. The ISP for Resident #1 was developed and signed by the facility staff and the person who completed the ISP on 11/02/2021. 2. There was no signature of the resident or resident?s legal representative on the ISP dated 11/02/2021.
Plan of Correction:	Cited Resident no longer resides at the community For current and future resident?s ISP?s will be reviewed for signatures by resident or legal representative and will be corrected for those missing signatures. Resident Care Director and Assistant Care Director will conduct ISP meetings and acquire signatures from residents and/or legal representative.[sic]
Standard #:	22VAC40-73-460-D
Description:	Based on staff interviews and documentation review, the facility failed to provide supervision of resident schedules, care, and activities including attention to the specialized need of wandering from the premises for one resident in care. EVIDENCE: 1. Resident #1 who has a physical dated and signed by a physician on 05/29/2019 indicating a current diagnosis of vascular dementia and documentation that she is not capable of self-preservation. The same physician signed and dated the assessment of serious cognitive impairment dated 05/29/2019, indicating Resident #1 is only oriented to person; has difficulty with processing; needs long term memory unit care; she is unable to recognize danger or protect her own safety and welfare; and she has a serious cognitive impairment due to a primary diagnosis of dementia. Resident #1 was admitted to the special care unit due to her cognitive impairment on 05/30/2019. 2. Resident #1 has a UAI (Uniform Assessment Instrument) reassessment dated 05/02/2022. The UAI indicates Resident #1 is disoriented to some spheres, all the time; spheres affected are time, place, and that she wanders passively weekly or more. 3. On 11/08/2021 at approximately 7:30 am Resident #1 held the fire door handle and after a time lapse the egress lock released and Resident #1 exited the special care unit. Resident #1 then attempted to exit loading dock area (approximately 100 feet away from the special care unit exit), but Staff #1 met Resident #1 at the door upon hearing the alarm sound and was able to redirect her back to the special care unit. 4. On 11/10/2021 at approximately 7:00 pm Resident #1 opened the door, held the lock until it released and traveled approximately 100 feet to the rear loading dock and was able to open the door and exited to the outside. During an interview with Staff #2, he stated as soon as the door alarmed he ran and immediately made visual contact with Resident #1. Staff #2 spoke with Resident #1 and decided it was best to walk with her around the building to the front entrance, he states this was approximately 500 feet. He continued to walk with her back to the special care.
Plan of Correction:	Release on mentioned fire egress door was approved by local Fire Marshall to disarm delayed release. Maintenance Director disarmed the door release which will no longer allow the door to release after being held. Review of documentation, schedules, care, and activities/programming to address the needs of those who wanders. Maintenance Director for the door; Resident Care Director, Assistant Resident Care Director and Program Director will be responsible for addressing the specialized need of wandering resident. [sic]
Standard #:	22VAC40-73-680-I
Description:	Based on a review of the MAR (Medication Administration Record), the facility failed to include the diagnosis, condition, or specific indication for administering the drug or supplement. EVIDENCE: 1. The November and December 2021 MAR for Resident #1 did not include the diagnosis for the following medications: Allopurinol, 300mg one tablet by mouth daily; Bicitracin Zinc ointment, apply topically to affected area liberally three times daily; Cholestyramine Oral Packet, mix one packet in 2-6 ounces of water or beverage of choice; Divalproex Sodium 250mg delayed release, take one tablet by mouth at bedtime, do not crush; Donepezil HCL 10mg, take one tablet by mouth at bedtime; Ensure vanilla liquid, drink one can by mouth with meals; Hydrocortisone/Aloe Max Cream 1%, apply topically to affected area three times daily; Hydroxyzine Pamoate 25mg, take one capsule by mouth twice daily; Loperamide HCL 2 mg, take two capsules by mouth every eight hours as needed; Lorazepam Oral Tablet .5mg, take half a tablet by mouth twice daily as needed.
Plan of Correction:	Physician notified for medications missing diagnosis. Medication Administration Record will be reviewed to ensure the diagnosis, condition, or specific indication for administering the drug or supplement is listed. Resident Care Director and Assistant Resident Care Director are responsible for physicians? orders have a diagnosis for each medication. [sic]