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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: Nov. 1, 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

Comments:
Type of inspection: Renewal
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/01/2022 Begin: 12:00pm-5:36pm
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
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.
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 B. Mullins, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations:
Standard #: 22VAC40-73-100-C-2
Description: Based on observation during an audit of medication carts, resident record review and staff interview, the facility failed to implement all sections of their infection control program.
EVIDENCE:
1. At approximately 11:16AM, the LI along with staff #2 observed a glucometer in medication cart 400 for resident #4 that was not labeled. The October 2022 medication administration record (MAR) for the resident contains documentation that the resident receives daily blood glucose readings. When the LI reviewed the facility?s infection control program during on-site inspection and interviewed staff #5 regarding the facility?s infection control policies in regards to glucometers, staff #5 gave the LI the following information from the facility?s clinical policy and procedure manual: ?Clinical 27 ? diabetes care ? 2. Glucometers are never to be shared with another resident. Each resident whose blood glucose is to be recorded must have their own glucometer and test strips for that device that are kept in the resident?s room unless it poses a risk for resident safety. If the glucometer and test strips must be centrally stored for safety, they will be clearly labeled.?

Plan of Correction: 1. Resident #2?s glucometer was labeled with the resident?s name.
2. The RCD/designee will perform routine glucometer checks to ensure each glucometer is labeled with the resident?s name, and that each glucometer is stored separately. [sic]

Standard #: 22VAC40-73-260-C
Description: Based on observation and staff interview, the facility failed to ensure the listing for all staff who have current certification in first aid or CPR indicated by staff person whether the certification is in first aid or CPR or both.
EVIDENCE:
1. When the LI observed the listing, it did not indicate whether the certification for staff members is in first aid, CPR or both. According to staff #5 this was accurate and is the only First Aid/CPR posting in the facility.

Plan of Correction: 1. The BOM was re-educated on the format for the staff listing of staff who have current certification in first aid and/or CPR. The location of the posting was moved to the main lobby.
2. The ED/Designee will check the listing monthly for three months to ensure the format of the list complies with 260C (A2).
[sic]

Standard #: 22VAC40-73-560-F
Description: Based on observation, the licensee failed to ensure all records were treated confidentially.
EVIDENCE:
1. At approximately 11:30AM, the LI observed medication cart 200 sitting outside of room 205, the laptop on top of the medication cart was opened and contained pictures of residents. Staff #4 was the assigned medication aid on this medication cart and when she returned to the cart she clicked on the pictures of the residents and was able to pull up medications that the residents were taking.

Plan of Correction: 1. Staff were re-educated that laptops should not be left open w/ resident information visible when staff are not present to protect resident confidentiality.
2. The Commonwealth IT department will be contacted to set shorter ?timeout? settings on the med cart laptops.
3. The ED/designees will round to ensure laptops do not have resident information visible when RMA staff are not present at the med cart. [sic]

Standard #: 22VAC40-73-610-B
Description: Based on observation during a tour of the facility?s safe, secure unit, the facility failed to ensure the menus posted for meals and snacks were for the current week.
EVIDENCE:
1. The menu posted in the facility?s safe, secure unit contained dates for the Fall and Winter of 2021 and 2022; November 1 was listed on the menu as a Monday; however, November 1, 2022 is Tuesday.

Plan of Correction: 1. The current menu was posted in Memory Care (MC) on 11/1/22.
2. The Dining Services Director/designee will ensure that the current menu is posted in MC each cycle.
3. The ED/designee will round weekly for four (4) weeks to ensure that the current menu is posted in MC. [sic]

Standard #: 22VAC40-73-640-A
Description: Based on observation during medication cart audits, resident record review, staff interview, the facility failed to implement their medication management plan.
EVIDENCE: 1. The facility?s med mgt plan indicates : ?No resident can be forced to take any medication. Steps will be taken to avoid missed or refused doses of medications and related adverse reactions.The prescribing physician is notified immediately or in the time frame and according to the parameters as indicated by the physician using the Refusal of Medication Notification form. Physician parameters must be retained in writing and filed in the chart under Physician Orders. The responsible party is notified. 3. The RCD re-appraises the resident and contacts the physician and responsible party if the resident is continually refusing a medication(s).? Resident #13's record contained a physician?s order, dated 09/20/2022, for Novolog 10 units before meals hold if blood sugar is less than 120 and a physician?s order, dated 06/29/2022, for Lantus inject 25 units twice daily at 9:00AM and 9:00PM. The October 2022 MAR for resident #13 contained documentation of numerous days from 10/1/22-10/25/22of the resident refusing her scheduled Lantus insulin and Novolog insulin; however, staff #5, did not send notification to the resident?s physician of these refusals until 10/26/2022 and did not use the ?Refusal of Medication Notification? form.
The facility?s medication management plan indicates the following in section 07 medications storage of centrally stored medications policy date 12/15/2021: ?Procedure ? 7. All multidose items shall have an open/start date. This includes creams, topicals, eye drops, ear drops, respiratory meds, powders, liquids, insulins, and nitroglycerin. 2. Med cart 200 contained: an opened bottle of Latanoprost eye drops for resident #13. a pen of Humalog 100U/ML for resident #14; and a pen of Novolog 100U/ML for resident #1; none contained an open date. 3. Med cart 300 had an opened vial of Lantus for resident #15 that did not contain an open date. The record for the resident contained a physician?s order, dated 07/13/2022, for Lantus 25 units daily at bedtime. The OCT 2022 MAR for the resident contained documentation that the resident did receive for Oct 22.4. Med cart 400 had Lantus opened,100U/ML for resident #4 with no open date. The record for the resident contained a physician?s order, dated 08/30/22, for Lantus inject 26 units every day in the afternoon. The Oct 22 MAR for the resident contained documentation that the resident did receive Lantus during the month of October.
5. The med mgt plan indicates the following in section 32 ? controlled substance management policy date 12/15/2021: ?Procedure: 3. The keys to medication carts and storage areas will remain.. the person assigned to the medication cart ..for the duration of their shift. a) the keys must remain in the possession of the designated medication staff person while on Community premises...Anytime the possession of keys is passed, both staff members will count all controlled substances and both staff members will sign-off on the Controlled Substance Shift Count form and note any discrepancies on the count.? and the plan also indicates that during shift change the off-going and on-coming Med Aides both sign the appropriate Controlled Substances Shift count form once the count is performed by both medication aides.
6. During the300 med cart audit, staff #2 informed LI she was given the keys to cart 300 at 9:00AM by staff #1. LI asked staff #2 if she performed the narcotic count with staff #1and staff #2 stated that they did; but, they did not sign the Controlled Substance Shift Count form. The Controlled Substance Shift Count form for 200 med cart was missing signatures for the off-going/off going staff members for Oct 22. The Controlled Substance Shift Count form the 300 cart was lacking signatures for the off-going/on-coming staff members from 10/27/22 -10/31/22.

Plan of Correction: 1. The RCD and RCC were re-educated on the requirement to notify the resident?s physician per policy, for each instance, when a resident refused their medications using the ?Refusal of Medication Notification? form, and that the RCD will contact the physician and responsible party if the resident is continually refusing a medication. RMA staff will also be educated on this requirement.
Resident #13?s provider and responsible party were notified of her continual refusals of her medications.
The RCD/Designee will review the Medication Administration Records of all community residents for refusals consistently to ensure the resident?s provider has been notified of the refusal, and that the provider and responsible party are notified of continuous refusals of a medication.
2. All medication carts were audited to ensure all open multi-dose items shall have an open/start date.A new Med Cart Audit has been created for daily RMA use, to include an audit of all open multi-dose items are labeled with the open/start date.The RCD, or designee will spot check at least one med cart weekly to ensure that opened multi-dose items are labeled with the open/start date.
3. Staff #2 and all RMA staff will be re-educated anytime the possession of keys is passed from one RMA/nurse to another, both staff members will count all controlled substances and both staff members will sign-off on the Controlled Substance Shift Count form and note any discrepancies on the count, and that during shift change the off-going and on-coming Med Aides/nurses must both sign the appropriate Controlled Substances Shift count form once the count is performed by both medication aides.The RCD/Designee will audit the Controlled Substance Shift Count weekly to ensure the counts have been completed, and both the off-going and on-coming RMA/nurse signed the count sheet to ensure compliance.
[sic]

Standard #: 22VAC40-73-660-B
Description: Based on observation during the tour of the building and resident record review, the facility failed to ensure that residents rated dependent in medication administration on their Uniform Assessment Instrument (UAI) did not store medications in their rooms.
EVIDENCE:
1. At approximately 11:40AM, the LI along with staff #4 observed three containers of Nystatin cream in resident #10?s bathroom that contained labels with the resident?s name.
2. The UAI for the resident, dated 08/31/2022, indicated that the resident requires medications to be administered/monitored by lay person. There were no physician?s orders stating the resident could self-administer any medications.

Plan of Correction: 1. The Nystatin cream observed in resident #10?s room was removed from her room. The resident was re-educated that staff must administer all medications. If resident #10 desires to self-administer her Nystatin cream or other medications, she will be evaluated for safety to self-administer, appropriate orders will be obtained, and the resident will be assisted with appropriate storage.
2. All other residents? rooms have been swept to remove medications present for residents who have not been approved to self-administer medications, and their responsible parties have been notified.
3. On-going room sweeps will continue to maintain compliance. [sic]

Standard #: 22VAC40-73-680-B
Description: Based on observation during an audit of the facility?s medication carts, the facility failed to ensure medications remained in the pharmacy issued container until administered to residents.
EVIDENCE:
1. Medication cart 200 contained multiple loose pills in the cart?s second and third drawers. The loose pills were also observed by staff #4.
2. Medication cart 300 contained a loose round, white pill with the inscription 54/27 and medication cart 400 contained multiple loose pills in the cart?s second and third drawers; these were observed by staff #4
3. The medication cart located in the facility?s safe, secure unit contained a total of 5 loose pills from the cart?s second and third drawers which was observed by staff #3.

Plan of Correction: 1. All medication carts were cleaned, and any loose pills observed in the drawers were removed. The carts were re-organized to prevent overcrowding.
2. New med carts were ordered from the pharmacy to allow more room to prevent damage to the med cards caused by overcrowding.
3. A new med cart audit tool was developed for daily RMA staff use to include checking each med cart for loose pills in the drawers.
4. The RCD/designee will spot check at least one med cart weekly to ensure there are no loose pills observed in the cart drawers for two (2) months, and monthly thereafter to ensure compliance. [sic]

Standard #: 22VAC40-73-680-D
Description: Based on resident record review, the facility failed to ensure medications were administered in accordance with the physician?s or other prescriber?s instructions.
EVIDENCE:
The record for resident #15 contained a physician?s order, dated 07/13/2022, for Novolog 10 units AC (before meals) if BG (blood glucose) greater than 250. The October 2022 medication administration record (MAR) contains documentation that the resident?s blood glucose was 204 at 8:00AM on 10/11/2022, 212 at 8:00AM on 10/12/2022, 122 at 8:00AM on 10/26/2022 and 120 at 12:00PM on 10/18/2022 meaning that the resident?s Novolog should have been held; however, the MAR contains documentation that Novolog was administered on these dates/times by staff #3
1.The record for resident #4 contained a physician?s order, dated 08/30/2022, for Humalog 10 units AC (before meals) if BS (blood sugar) greater than 250.The October 2022 medication administration record (MAR) contains documentation that the resident?s blood sugar was 267 at 4:30PM on 10/27/2022 meaning that the resident?s Humalog should have been administered; however, the MAR contains documentation by staff #3 that Humalog was withheld per doctor orders at 4:30PM.

Plan of Correction: 1. Staff #3 is no longer employed by the community.
2. Resident #15?s and #4?s providers and responsible parties have been notified of the errors observed by the IL.
3. RMA staff will be re-educated on managing insulin orders with parameters, including when to hold insulin and when to give insulin based on BS readings starting on 11/14/22.
4. All resident insulin orders using ?<?, ?>? symbols were clarified to use ?greater than? or ?less than? instead of symbols.
5. The RCD/designee will review the medication administration records for all residents who have insulin orders with parameters three (3) times weekly for one month, then weekly for an additional month to ensure insulin administration is being completed accurately based on the order. [sic]

Standard #: 22VAC40-73-680-I
Description: Based on resident record review, the facility failed to ensure the medication administration record (MAR) contained all required components.
EVIDENCE:
1. The record for resident #14 contained an order, dated 10/19/2022, for Humalog sliding scale insulin, <60=notify MD, 60-149=0U; 150-200=6U, 201-250=8U; 251-300=10U; 301-350=12U; 351-400=14U; >400=notify MD.
The October and November 2022 MARs for resident #14 did not contain documentation of the number of units of Humalog that were administered for the following dates and times: 10/26/2022 at 4:30PM, 10/27/2022 at 6:00AM and 4:30PM, 10/28/2022 at 4:30PM and 8:00PM, 10/29/2022 at 4:30PM, 10/30/2022 at 4:30PM, 10/31/2022 at 6:00AM, 11:30PM and 8:00PM and 11/01/2022 at 6:00AM and 11:30AM.
The October and November 2022 MARs for resident #14 did not contain documentation of what the resident?s blood sugar was prior to the resident being administered Humalog on the following dates and times: 10/26-30/2022 at 4:30 PM and 10/31/2022 at 11:30AM.

Plan of Correction: 1. Resident #14?s sliding scale insulin order was discontinued. All resident insulin orders using ?<?, ?>? symbols were clarified to use ?greater than? or ?less than? instead of symbols.
2. The community house pharmacy was contacted and will review their ability to add the instructions and set up set up documentation for sliding scale insulin orders in Quick MAR to ensure they are set up accurately to include the BS reading, and the number of units administered.
3. The RCD/designee will review the order set up in Quick MAR, prior to order approval, to ensure that the required components of the BS reading, and number of units administered can be documented.
4. The RCD/designee will review all insulin orders weekly for one month to ensure that new sliding scale orders have been set up to allow BS readings and number of units administered to be documented, and that orders with parameters do not contain symbols.
[sic]

Standard #: 22VAC40-73-870-A
Description: Based on observation during a tour of the building, the facility failed to ensure the building was maintained in good repair, kept clean and free of rubbish.
EVIDENCE:
1. The entry wall in room 207 contained multiple areas of staining.
2. Room 210 had multiple walls with black scuff marks.
3. The entry wall in room 215 contained black scuff marks along the baseboard, the toilet in the bathroom contained multiple brown stains on the toilet lid and around the top of the toilet bowl, and the seat of the wheelchair used by the resident who resides in room 215, contained multiple areas of staining which was also observed by staff #4.
4. The sitting area and dining room floor in the facility?s safe, secure unit was extremely sticky which was observed by two LIs and staff #3.The bottom of the door in the safe, secure unit located near the sitting area contained multiple black marks and multiple walls in the safe, secure unit contained black marks throughout the dining room and the sitting area.
5. The floor in resident #11?s room was dirty and sticky and the seat of the shower chair located in the resident?s shower contained a large brown stain.
6. The floor in front of the bedside table in room 112 contained multiple crumbs of food and the sink in the bathroom contained an empty snack wrapper and a piece of used gaze with adhesive tape.
7. The floor in room 101 was dirty and sticky and the toilet in the bathroom of room 101 contained multiple dried areas of the brown substance in the toilet bowl.
8. The floor of the kitchen area in room 409 was observed to be dirty with crumbled cookie crumbs.

Plan of Correction: 1. The entry wall in 207 was cleaned, the scuff marks on the wall in 210 were removed, room 215 was painted, the toilet was cleaned, 215?s w/c was pressure washed, the floor in the dining room and sitting areas in the MC unit were cleaned w/ the appropriate solution, the walls in the secured unit were painted, resident #11?s floor and shower chair were cleaned, the floor and the sink in room 112 was cleaned, room 101?s floor and bathroom were cleaned.
2. The Maintenance Director/ designee will monitor resident rooms weekly for one month, and then monthly thereafter for cleanliness and scuff marks to ensure compliance with housekeeping standards.
Resident rooms will be monitored for necessary repairs and identified needs will be addressed at that time.
3. Direct care staff will be re-educated to clean shower chairs after each use.
4. The RCC/Designee will spot check all resident rooms where showers were provided the prior day weekly for one (1) month to ensure that the shower chairs have been cleaned.
[sic]

Standard #: 22VAC40-73-870-B
Description: Based on observation, the facility failed to ensure the building was free from foul, stale and musty odors.
EVIDENCE:
1. The LI along with staff #3 noted resident #9?s room had a strong smell of feces and urine.

Plan of Correction: 1. Resident #3 and #9?s rooms have been deep cleaned. All of resident #9?s clothing in her closet was washed, and she has been provided with a new mattress.
2. All resident rooms are being deep cleaned, and families are being requested to replace furniture/mattresses that have odors that were not removed from shampooing/extraction.
3. A new housekeeping/ maintenance cadence has been created to address odors. Staff will be educated on the cadence the week of 11/14/22, and it will be implemented thereafter.
4. All staff will be educated to report soiled furniture to maintenance for cleaning and on the need to check each resident?s room for soiling and odors. [sic]

Standard #: 22VAC40-73-870-E
Description: Based on observation during a tour of the building, the facility failed to ensure all furnishings were kept in good repair and condition.
EVIDENCE:
1. The LI observed that the seat cushion material of two chairs in the assisted living dining room was coming apart.
2. The seat cushion in room 409 was found to have a brown stain approximately eight inches in size. The appearance and smell indicated feces had been left in the chair.

Plan of Correction: 1. The two damaged chairs in the dining room were disposed of.
The community is working on replacing all the dining room chairs. A plan for replacement will be completed by 11/18/22.
The Maintenance Director will examine dining room chairs weekly until new chairs are obtained. Chairs found in disrepair will be removed from service until repaired or replaced.
A new maintenance cadence has been created. Staff will be trained, and the cadence will be implemented by the week of 11/14/22, and it will be implemented thereafter.
2. The chair in room 409 was cleaned.
Staff will be educated to report soiled furniture to Maintenance for cleaning.
3. The Maintenance Director/ designee will audit resident rooms weekly for soiled furniture for one month, and monthly thereafter to ensure 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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