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 RESIDENT CARE AND RELATED SERVICES

Comments:

Two licensing inspectors conducted a one day self-report monitoring inspection at Commonwealth Senior Living-Christiansburg on 01/04/2022. Information regarding several self-reports and complaints was collected and reviewed and the LI requested additional records to follow. An exit meeting was held with the administrator of the facility on 01/04/2022 and the new administrator on 04/21/2022. One violation is being cited as a result of this self-reported incident. If you have any questions please feel free to contact your inspector at 276-608-1067. Thank you for your assistance and cooperation.

Violations:

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) dated 11/02/2021. The UAI indicates Resident #1 is disoriented to some spheres, all the time; spheres affected are time, place, situation, and that she wanders passively weekly or more. 3. According to Staff #1 on 12/30/2021 at approximately 6:30 pm when she returned from break the alarm on the secure unit door sounded but no one was seen exiting building. Staff #1 states this is when Resident #1 left the building by holding the fire door handle and after a time lapse the egress lock released and Resident #1 exited the special care unit to the outside. 4. According to a statement from Staff #1, she noticed Resident #1 was missing at the time she was administering 8:00pm medications. Staff #1 notified additional staff and called 911. 4. Resident #1 traveled across six lanes of traffic at a busy, four- way intersection; approximately a half of a mile away from the facility where she was then located by the police. The police department contacted staff. Resident #1 was transported back to the facility by police along with Staff #1 at 10:49pm with no problems. 5. Staff #2 states she assessed Resident #1 and found no injuries. Resident #1 was offered and accepted food and hydration by Staff #2. Staff #2 stated Resident #1?s vitals were stable
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 wander. 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]