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 and information 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 has a physical dated and signed by a physician on 11/26/2021 indicating a current diagnosis of dementia. The same physician signed and dated the assessment of serious cognitive impairment 11/26/2021, indicating "declined" in regards to thought and perception. The physician also documented Resident #1 has been "wandering recently" regarding her behavior/psychomotor actions and the physician checked the box to confirm Resident #1 has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia, and also checked the box to confirm Resident #1 is unable to recognize danger or protect his/her own safety and welfare, all documented on the assessment of serious cognitive impairment signed by a physician on 11/26/2021. 2. Resident #1 was admitted to the safe and secure unit of this facility on 11/26/2021 as a result of the physician documentation. 3. Resident #1 has a preliminary Individualized Service Plan dated 11/26/2021; the ISP indicates Resident #1 is disoriented to person, place and time and she was assessed as an elopement risk. 4. According to a statement from Staff #1, on 11/27/2021 at 4:12 pm she realized Resident #1 was not able to be located in the facility and 9-1-1 was contacted at 4:23 pm. Resident #1 was discovered at 4:45 pm when Staff #1 observed law enforcement walking with Resident #1 down the gravel driveway, according to Staff #1 the resident stated she "just wanted to take a walk". According to Staff #2, the resident was discovered approximately 300 feet away from the front entrance of the facility. 5. Staff #1 states she met law enforcement with resident and guided her back into the facility safely and into the safe, secure unit. Resident #1 was observed to have small scrapes to her lower leg and denied any pain or discomfort.
Plan of Correction:	The staff member that allowed the resident to exit the memory care unit of the community has been re-educated regarding the cognitive impairments that affect the residents on the memory care unit. Re-education was provided regarding the importance of only allowing residents on the memory care to exit the unity when accompanied by either a family member/visitor or a commonwealth staff member. The community staff will be re-educated by 05/20/2022 and ongoing regarding the cognitive impairments that affect the residents on the memory care unit. Re-education will be provided by 05/20/2022 and ongoing regarding the importance of only allowing residents on the memory care unit to exit the unit when accompanied by either a family member/visitor or a commonwealth staff member. RCD/Designee. [sic]