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: April 11, 2022

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 ACCOMMODATIONS AND RELATED PROVISIONS ? 22VAC40-73 BUILDINGS AND GROUND ? 22VAC40-73 EMERGENCY PREPAREDNESS ? 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ? ARTICLE 1 ? SUBJECTIVITY ? 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS ? 63.2 GENERAL PROVISIONS ? 63.2 PROTECTION OF ADULTS AND REPORTING ? 63.2 LICENSURE AND REGISTRATION PROCEDURES ? 63.2 FACILITIES AND PROGRAMS ? 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES ? 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION ? 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT ? 22VAC40-80 THE LICENSE ? 22VAC40-80 THE LICENSING PROCESS ? 22VAC40-80 COMPLAINT INVESTIGATION ? 22VAC40-80 SANCTIONS

Comments:

Comments/Discussion: Type of inspection: Renewal On 04/11/2022 the licensing inspector was on-site at the facility from 9:05 am until 4:09pm on the date of the inspection. The Acknowledgement of Inspection form was signed and left at the facility on 04/11/2022. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. (06/05/2022) Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal Mullins, Licensing Inspector at (276)608-1067 or by email at crystal.b.mullins@dss.virginia.gov Violation Notice Issued: Yes A copy of this document will be sent to the licensee/provider for signature. Inspector Name: Crystal B. Mullins Date Inspection Summary Issued: 5/31/2022

Violations:

Standard #:	22VAC40-73-250-C
Description:	Based on review of staff records, the facility failed to ensure that each staff member has a sworn disclosure statement in their record. EVIDENCE: 1. Staff #8 was hired on 03/21/2022. No sworn disclosure statement was available in Staff #8?s record. 2. Staff #9 was hired on 03/09/2022. No sworn disclosure statement was available in Staff #9?s record. 3. Staff #10 was hired on 03/03/2022. No sworn disclosure statement was available in Staff #10?s record. 4. Staff #11 was hired on 03/03/2022. No sworn disclosure statement was available in Staff #11?s record.
Plan of Correction:	Sworn Disclosure statements have been obtained for staff members #8, 9, 10, and #11. The Business Office manager has completed an audit for current staff members to ensure that the sworn disclosure statements have been completed and are available in the employee?s personnel file.The Business Office manager/designee will conduct a weekly audit of all new hires each week to ensure that a sworn disclosure statement has been performed. The Business office manager/designee will also conduct a monthly audit of 10 employee files to ensure that the sworn disclosure statements are
Standard #:	22VAC40-73-320-B
Description:	Based on resident record review, the facility failed to ensure that a risk assessment for tuberculosis (TB) shall be completed annually on each resident. EVIDENCE: 1. Resident #1 was admitted to the facility on 03/26/2021. On the date of the inspection, 04/11/2022, the file did not contain an annual TB risk assessment.
Plan of Correction:	Resident #1 has received her annual TB risk assessment. The current residents of the community have been audited to ensure that the annual TB screening has been completed for each current resident. The RCD/Designee will conduct a monthly audit of current residents to ensure that the annual TB screening has been conducted for each resident. [sic]
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review, the facility failed to ensure the Uniform Assessment Instrument (UAI) for private pay individuals had been completed as required. EVIDENCE: 1. The UAI for Resident #2, dated 02/21/2022, indicated bathing as a need and required mechanical assistance and human supervision; however, the Individualized Service Plan (ISP) for Resident #2, dated 04/01/2022, indicated that this resident requires mechanical assistance and physical assistance for bathing. 2. Interview with Staff #2 determined that the resident?s ISP was correct.
Plan of Correction:	Resident #2?s UAI has been corrected to be reflective of the information included on the ISP. An audit of current residents UAI?s and ISP?s was conducted to ensure that both are accurate for each resident. Any discrepancies noted will be corrected. The RCD/designee will randomly audit 10 resident UAI?s and ISP?s per month to ensure that they are accurate and have the same information regarding the residents? plan of care. [sic]
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure that the comprehensive Individualized Service Plan (ISP) shall include a description of identified needs based upon the UAI as well as other sources. EVIDENCE: 1. The ISP for Resident #2 dated 04/01/2022, indicated for transferring, this resident requires mechanical and physical assistance; however, the UAI dated 02/21/2022, indicated transferring for this resident requires only physical assistance. 2. Interview with Staff #2 determined that the resident?s UAI was correct. 3. Resident #9 has an ISP dated 04/11/2022. This resident is receiving hospital per a physician?s order, this is not listed as a service provided on the ISP. This resident also had half rails on her hospital bed in her room, this was not listed as a service on the ISP.
Plan of Correction:	The ISP for resident #2 has been updated to show that the resident requires physical assistance as indicated on the UAI. Resident #9 has passed away. An audit of current residents UAI?s and ISPs was conducted to ensure that both are accurate for each resident. Any discrepancies noted will be corrected. The RCD/designee will randomly audit 10 resident UAI?s and ISPs per month to ensure that they are accurate and have the same information regarding the resident?s plan of care. [sic]
Standard #:	22VAC40-73-560-F
Description:	Based on observation, the facility failed to ensure that all records are treated confidentially and information shall be made available only when needed for care of the resident. EVIDENCE: 1. During the physical plant tour of the facility, the LI observed that the narcotic count log books for carts C and D, which contained resident medication information, were stored on top of the medication carts while they were not in use.
Plan of Correction:	The community staff have been re-educated regarding confidentiality of resident health information. The narcotic books will be stored in the medication carts when not in use, and the med cart tablets closed when not in use. The RCD/designee will conduct weekly med cart audits to ensure that the narcotic books are locked in the medication carts when not in use, and that the med cart tablets are closed when not in use. [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on record review, the facility failed to implement its medication management plan specifically with regard to methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility?s medication management plan, dated 12/15/2021, states ?1. Shift counts are performed at the end of each shift or when the person responsible for medications changes?Whenever a Med Aide leaves the floor and another Med Aide is responsible for meds, a complete count will take place by the person going off the cart and the person coming on the cart?4. If the quantity is verified, the off-going and on-coming Med Aides both sign the appropriate Controlled Substance Shift Count form.? The facility?s MMP also states ?5. If the quantities differ, (a) The off-going and on-coming Based on record review, the facility failed to implement its medication management plan specifically with regard to methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility?s medication management plan, dated 12/15/2021, states ?1. Shift counts are performed at the end of each shift or when the person responsible for medications changes?Whenever a Med Aide leaves the floor and another Med Aide is responsible for meds, a complete count will take place by the person going off the cart and the person coming on the cart?4. If the quantity is verified, the off-going and on-coming Med Aides both sign the appropriate Controlled Substance Shift Count form.? The facility?s MMP also states ?5. If the quantities differ, (a) The off-going and on-coming Med Aides will perform a recount to ensure a simple counting error was not made? (c)? medication not used according to the MAR or PRN record, this must be documented on the Controlled Substance Shift Count form and the Executive Director notified immediately.? 2. During the facility?s medication cart audits at approximately 10:00 AM, the LI reviewed the narcotic count logs for Cart D (400 hallway) and Cart C (300 hallway). As a result it was observed that one narcotic count was inaccurate for the following dates and times: For Cart D (400 hall), on 03/23/2022 and 03/24/2022, for the 3 PM ? 11 PM shift, the oncoming staff member did not sign the log and the Count Discrepancies Found box was incomplete; On 03/25/2022, for 3 AM -7 AM, the off-going staff member did not sign the log; On 03/28/2022, for the 3 PM -11PM shift, the oncoming staff member did not sign the log; On 03/29/2022, the log was not completed or signed by any staff for any shift; On 3/30/2022, for the 3 PM ? 11 PM shift, the oncoming staff member did not sign the log. For Cart C (300 hall), on 03/27/2022 and 03/28/2022, the oncoming staff member did not sign the log; On 03/30/2022, for the 3 PM ? 11 PM shift, the oncoming staff member did not sign the log and the Count Discrepancies Found box was incomplete; On 03/31/2022, for the 11 PM -7 AM shift, the off-going staff member did not sign the log; On 04/01/2022, for 11 PM -3 AM, the off-going staff member did not sign the log.
Plan of Correction:	The med carts in the community have been audited by the RCD to ensure that all narcotic counts are currently accurate. The Community staff have been re-educated regarding the proper procedure for signing off the narcotic count sheets from shift to shift The RCD/designee will conduct weekly med cart audits to ensure that the narcotic counts are correct, and that the community staff are following the proper policy and procedure as it relates to counting the narcotics and signing off the narcotic count sheets in every sheet. [sic]
Standard #:	22VAC40-73-700-1
Description:	Based on review of resident records, the facility failed to ensure the physician or other prescriber?s order included the source of the oxygen such as compressed gas or concentrator. EVIDENCE: 1. Resident #8 has a physician?s order dated 07/02/2020 for oxygen 2 liters at night via nasal cannula. The order did not contain the source of the oxygen.
Plan of Correction:	Resident # 8?s order for O2 has been clarified to include the source of the oxygen. Current residents of the community have been audited to ensure that residents with O2 have the proper verbiage to show the source of the oxygen. The RCD/Designee will keep a list of those residents with orders for O2 and will audit those orders each month to ensure that the orders are accurate and state the source of the oxygen. [sic]
Standard #:	22VAC40-73-710-C
Description:	Based on review of resident records and resident interviews, the facility failed to have a valid physician?s order that specified the condition, circumstances, and duration under which a restraint is to be used. EVIDENCE: 1. Resident #9 has half rails on her hospital bed in her room. Resident #9 was not able to voice to the LI what the half rails were used for. 2. Resident #9?s file did not have a physician?s order for the bedrails.
Plan of Correction:	Resident #9 has passed away. Prior to her passing, the half rails were removed from her bed and a low bed with a fall mat was put into place. The RCD/Designee will keep a list of those residents with bed side rails. Those residents with side rails will be reviewed monthly to ensure that an order for the side rails is in place and that the resident is able to voice why the side rails are being used. [sic]
Standard #:	22VAC40-73-980-H
Description:	Based on observation, the facility failed to ensure the availability of a 96-hour supply of emergency food and drinking water. At least 48 hours of the supply must be on site at any given time, of which the facility?s rotating stock may be used. EVIDENCE: 1. Staff #1 reported that the facility?s census was 57 on 04/11/2022. 2. During the morning tour of the building the LI and Staff #1 observed the facility?s emergency food and water supply and noted an adequate amount was not readily available. The LI located 24 bottles which held 16.9 fluid ounces. This does not suffice the one gallon of water per resident per 24 hour period based on the facility?s census of 57.
Plan of Correction:	The community has purchased and placed in the basement storage area 96 hours of emergency water supply. There are currently 400 gallons of water in the storage area. The Dining Services Director will check the storage area once a month to ensure that there is always an adequate supply of water on hand. [sic]
Standard #:	22VAC40-90-40-B
Description:	Based on observations made during review of staff records, the facility failed to ensure a criminal record history report had been obtained on two employees prior to the 30th day of employment. EVIDENCE: 1. Staff #13 was hired on 02/14/2022. On the date of inspection, 04/11/2022, there was no criminal background record available for Staff #13. 2. Staff #14 was hired on 09/20/2021. On the date of inspection, 04/11/2022, there was no
Plan of Correction:	Criminal Background checks have been obtained for both staff members #13 and #14. The Business Office manager has completed an audit for current staff members to ensure that the criminal background check has been completed and is available in the staff members? personnel file. __X_ Yes ___ No How Will Recurrence Be Prevented? The Business Office manager/designee will conduct a weekly audit of all new hires each week to ensure that a criminal background check has been performed. The Business office manager/designee will also conduct a monthly audit of 10 employee files to ensure that the background checks are present in the employee's personnel files. [sic]