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: Dec. 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: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/01/2022 Begin: 10:00am End: 3:50pm 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. Henson, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on a review of medication carts, resident records and medication administration records, the facility failed to follow some components of their medication management plan (MMP). EVIDENCE: 1. The facility MMP has documentation under Med-10 Handling, Ordering and Refilling Medications ?If the house pharmacy delivers medications to the community as part of their service agreement, all routine medications should be ordered prior to the blister card running out. ?On Demand? refills may be faxed 24 hours a day. Please allow 5 days for refills. Adhere to the following rules to avoid delay. Use the refill re-order form.? The record for resident 7 has a physician order for Hydroco/Apap 7.5-325mg 1 tablet by mouth every 6 hours for pain. The November 2022 MAR for resident 7 has staff initials that are circled as not administering this medication at 12pm and 6pm on 11/22/2022. The MAR has documentation of waiting on pharmacy. 2. The record for resident 10 has a physician order for Fluticasone-Salmeterol 100-50, inhale 1 puff by mouth every 12 hours for asthma. The November 2022 MAR for resident 10 has staff initials that are circled as not administering this medication at 9am and 9pm from 11/25 through 11/29. The MAR has documentation of waiting on pharmacy. 3. The facility MMP has documentation under Med-26 Administering and Assisting with Injections ?Once an injectable medication is opened follow the expiration date according to manufacturer?s instruction. A Novolog Flexpen Insulin for resident 8 was noted to be open in the medication cart. The insulin pen did not contain an open date to be able to discard within 28 days of opening per manufacturer?s instructions.
Plan of Correction:	1. Resident # 7?s hard script for Hydrocodone was received at the pharmacy on 11/22/22, and her medications were delivered to the community on 11/22/22. Resident #10?s Fluticasone was delivered on 11/29/22. Resident #8?s Novolog was immediately dated with date opened. 2. The RCD/Designee were re-educated to ensure that an appropriate start date/time is indicated during the approval process for all new/updated orders. RMA?s will be re-educated on the processes of refilling medications and on the process for labeling/dating medications with the date opened/started. 3. Medication cart audits will be completed twice a week for 4 weeks to ensure medications are available to be administered as ordered, and that all multi-dose medications are labeled with the date opened/started. [sic]
Standard #:	22VAC40-73-660-A
Description:	Based on observations of the facility medication carts, the facility failed to ensure that medications requiring refrigeration were refrigerated. EVIDENCE: 1. An unopened bottle (orange snap cap still attached) of Novolog 100u/ml insulin was observed on the medication cart for resident 9. Manufacturer?s instructions are to refrigerate this medication until it is opened for use.
Plan of Correction:	1. Resident #9?s vial of insulin was replaced. 2. RMA staff were re-educated that insulin requires refrigeration prior to opening. 3. Medication carts will be audited by the RCD/designee twice a week for 4 weeks to ensure that unopened insulins are not being stored on the medication carts. [sic]
Standard #:	22VAC40-73-660-B
Description:	Based on observations made during the tour of the building and resident record review, the facility failed to ensure there were no medications in resident rooms for one resident who is rated dependent in medication administration. EVIDENCE: 1. Resident #7 has a UAI dated 9/15/22 which documents medication administration is preformed by a layperson in the facility. 2. Resident #7?s room was observed to be open, and no one was inside the room when two Lis entered. The LIs observed Equate nasal spray sitting on a desk and an 8-ounce bottle of Walgreen?s mouth rinse containing hydrogen peroxide which states it is an oral debriding agent-which was found sitting on the vanity area of the bathroom sink. 3. Resident #7?s file does not contain a physician?s order to allow this resident to self-administer any medication.
Plan of Correction:	1. Resident #7?s nasal spray and mouth rinse was immediately removed from the resident?s room. Resident #7?s provider was contacted to request an order for the saline spray. The resident?s family will be requested to provide non-medicated mouth rinse 2. All residents and responsible persons were notified that residents may not store medications or medicated products in their room unless they have been approved to self-medicate. Staff have been re-educated that residents may not store medications or medicated products in their room unless they have been approved to self-medicate and instructed to immediately notify the ED/RCD or designee if medications/medicated products are observed stored in a resident?s room. 3. Room sweeps will continue weekly for an additional 4 weeks to ensure compliance. [sic]
Standard #:	22VAC40-73-680-D
Description:	Based on a review of resident records and medication administration records (MARs), the facility failed to ensure that medications were administered in accordance with physician instructions. EVIDENCE: 1. The record for resident 6 has physician orders for Carvedilol 3.125mg, 1 tablet twice daily for coronary artery disease and Isosorbide Mono 60mg every day for hypertension. Both medications are to be held if systolic less than 120 and heart rate less than 60. Staff initials are circled on the November 2022 MAR as not administering both medications at 8am on 11/2, 11/3, 11/6 through 11/10, 11/13, 11/18 through 11/21 and for the 8pm dose of Carvedilol on 11/5 through 11/7. Documentation on the MAR indicates that these medications were withheld per DR/RN orders but documentation of resident 6?s blood pressure and heart rate results indicate that they were not within the parameters to hold these medications. 2. The record for resident 9 has a physician order for Novolog Insulin inject 5 units SQ if blood sugar is greater than 250. The November 2022 MAR for resident 9 has documentation of the residents blood sugar being 288 at 8pm on 11/29, 267 at 11:30am on 11/30 and 280 at 8pm on 11:30. There is no documentation the 5 units of Novolog insulin was administered for these blood sugars.
Plan of Correction:	1. Resident #6?s Carvedilol and Isosorbide parameter orders were clarified. Resident #9?s PRN Novolog order was clarified/reformatted to ensure that the BS is documented as a part of the Novolog administration order. 2. Parameter orders will be reviewed with providers to ensure the parameters were necessary to ensure the resident?s optimal health/safety. All remaining medication orders with parameters were reviewed by the RCD/designee for clarity. RMA staff will be re-educated to use caution with medication parameters to ensure they are followed accurately on 12/7/22. 3. The RCD/designee will continue to monitor medication administration records at least twice weekly for an additional month to ensure that parameters are being followed accurately. [sic]
Standard #:	22VAC40-73-680-E
Description:	Based on a review of resident records and medication administration records (MARs), the facility failed to ensure that treatments and procedures ordered by a physician were provided according to their instructions. EVIDENCE: 1. The record for resident 6 has a physician order for TED stockings, put stockings on in the morning and take off at bedtime for edema. The November 2022 MAR for resident 6 has staff initials that are circled as not applying the TED stocking from 11/5 through 11/12. Documentation on the MAR indicates that TED hose not in cart or residents room.
Plan of Correction:	1. Resident # 6?s TED Hose have been discontinued. 2. RMA staff will be re-educated to call the Pharmacy to determine what is needed to secure medications or treatment supplies that are not available for immediate administration, to follow-up on necessary steps to secure the medication/treatment supplies, and to document efforts/actions in the resident?s clinical record. Concerns should be immediately communicated to the RCD/Designee. 3. The RCD/designee will continue to monitor medication/treatment administration records at least twice weekly for an additional month to ensure that all medications/treatments have been administered as ordered. [sic]
Standard #:	22VAC40-73-860-I
Description:	Based on observations made during the tour of the building, the facility failed to store cleaning supplies and other hazardous materials in a locked area. EVIDENCE: 1. Resident #7?s room was observed to have the door fully open, and no one was present inside the room when two LIs entered. A 16-ounce bottle of 70% Isopropryl Alcohol was observed sitting out on the vanity area of the bathroom sink. 2. A bottle of 91% Isopropol Alcohol and a spray bottle with a blue liquid substance was noted in the unlocked cabinet under the sink in the bathroom of the wellness center. 3. At 10:00am a housekeeping cart with multiple cleaning agents sitting out on top was observed by the LI and staff 5 sitting in the hallway by the bathrooms near the conference/private dining room. 4. A container of SWOVO Disinfectant wipes was observed by the LI and staff 4 sitting out on the top shelf of the 200 Hall medication cart.
Plan of Correction:	1. The bottle of rubbing alcohol and mouthwash were removed from resident #7?s bathroom. The bottle of rubbing alcohol was removed from under the Chapel sink. The housekeeping cart was immediately secured, and the housekeeper re-educated to secure carts whenever the cart is not attended. The disinfectant wipes were immediately removed from the tops of all med carts and secured within the locked carts. 2. All resident rooms and common areas will be swept to ensure that no hazardous substances are accessible to residents. All staff will be re-educated that hazardous substances stored in resident?s rooms or in common areas must be secured and that residents who are not approved for self-administration may not have medications stored in their room, and that residents should be encouraged to lock their doors when they are not present in their rooms; staff will be re-educated to report non-compliance to ED/RCD or designee. Letters will be sent to all AL residents and residents? families re-educating the requirement that no resident who is not approved to self-medicate may store medications in their rooms, that any hazardous chemical must be secured from other residents, and that residents are encouraged to lock their apartment doors when they are not present. All residents will be re-issued room keys to ensure that they are able to lock their apartments when they are not present. All housekeepers will be educated that carts must be secured when they are unattended. 3. Room sweeps, and med cart observations will continue weekly for an additional 4 weeks to ensure compliance. [sic]