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: Sept. 14, 2023

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: 09/14/2023 Begin: 9:50AM End: 5:28PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed: 4 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 2 Observations by licensing inspector: n/a Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. 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. OPTION 2 - For Monitoring or Renewal Inspections WITH NO Violations The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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 #:	22VAC40-73-1070-B
Description:	Based on observations made during a tour of the building, the facility failed to ensure that when there are indications that ordinary materials or objects may be harmful to a resident with a serious cognitive impairment, these materials or objects shall be inaccessible to the resident except under staff supervision. EVIDENCE: 1. In the safe secure unit, the LI observed four loose furniture screws in the unsecured drawer of an end table in the sitting area located at the end of the hallway near the door labeled Stair A.
Plan of Correction:	1. Corrected at time of survey. 2. Daily sweeps of the safe secure unit will take place during the next 30 days to ensure compliance. [sic]
Standard #:	22VAC40-73-1110-B
Description:	Based on resident record review, the facility failed to complete a six-month review of the appropriateness of placement and continued residence for one resident who resides in the safe, secure environment. EVIDENCE: 1. Resident #6 was admitted to the facility on 01/27/2023 where she was admitted to the safe, secure unit. The facility failed to complete a six month review of the appropriateness of placement for resident #6 to remain in the safe, secure unit.
Plan of Correction:	1. RCD/Designee will conduct an audit of current residents who reside on the safe, secure environment to ensure six month reviews for appropriateness of placement are in compliance. Resident #6?s review of appropriateness has been completed. [sic]
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure the physical exam within 30 days preceding admission had all known allergies of each resident and a description of the person?s allergies. EVIDENCE: 1. Resident #2 was admitted to the facility on 12/05/2022. The physical was completed by a physician on 12/02/2022. The physical contained a list of allergies including: azithromycin, latex, Tessalon pearls, codeine. There were no reactions listed for any of the above-mentioned allergies. 2. Resident #3 was admitted to the facility on 08/22/2023. The physical was completed by a physician on 08/15/2023. The physical contained a list of allergies including: cipro, lovastatin, Cymbalta, Flexeril, Lasix, Levaquin, Lipitor, Monistat, Wellbutrin, iodine, latex, and Vick?s Vapor Inhaler. There were no reactions listed for the above-mentioned allergies. 3. Resident #4 was admitted to the facility on 09/30/2022. The physical was completed by a physician on 09/14/2022 and included the following allergies: Alendronate, Astemizole, Cefuroxime, Codeine, Meperidine, Sulfa, and Nitrofurantoin. There were no reactions listed for the above-mentioned allergies. There were no reactions listed for the above mentioned allergies.
Plan of Correction:	1. RCD/Designee will ensure physical exams on new admissions within 30 days preceding admission will list known allergies and type of reaction for each allergy, or request provider include unknown if reaction is unknown. 2. RCD/Designee will review and update Resident physicals on residents #2, #3, and #4 to include reactions to allergies. 3. RCD/Designee will audit current charts to ensure allergy reactions are listed and will review all new admission physicals to ensure compliance. [sic]
Standard #:	22VAC40-73-380-A
Description:	Based on review of resident records, the facility failed to include all required information on the resident personal and social data information. EVIDENCE: 1. Resident #3 was admitted to the facility on 08/22/2023. The resident personal/social data has blanks for the following areas: last home address, address from which received, birthplace, allergies, service in armed forces, information on advanced directives, responsible individual, clergyman/place of worship, next of kin, personal dentist, local department of social services, other agencies if involved, and current behavioral and social functioning. 2. Resident #5 was admitted to the facility on 08/29/22023. The resident personal/social data has blanks for the following areas: clergyman/place of worship, next of kin, the entire second page of the resident personal/social data was left blank. 3. Resident #6 was admitted to the facility on 01/27/2023. The resident personal/social data has blanks for the following areas: admission date, allergies, responsible individual, clergyman/place of worship, personal physician, personal dentist, local department of social services, and other agencies involved.
Plan of Correction:	1. The resident personal and social data information will be completed per regulatory standards prior to or at time of admission, and personal social data will be updated as warranted. 2. Current resident charts will be audited to ensure resident and social data forms are complete with no blanks / missing information. [sic]
Standard #:	22VAC40-73-410-A
Description:	Based on review of resident records, the facility failed provide an orientation for new residents and their legal representatives. An acknowledgement of having received the orientation shall be signed and dated by the resident or legal representative and kept in the resident?s record. EVIDENCE: 1. Resident #3 was admitted to the facility on 08/22/2023. There was no resident orientation in resident #3?s file on the date of the inspection. 2. Resident #4 was admitted to the facility on 09/30/2022. There was no resident orientation in resident #4?s file on the date of inspection.
Plan of Correction:	1. Orientation will be provided for new residents and their legal representatives upon admission. 2. Resident orientation will be provided for resident # 3 and resident #4. 3. ED/BOM/Designee will ensure new residents and their legal representative are provided with an orientation and that an acknowledgement of having received the orientation will be signed and dated by the resident or legal representative and kept in the resident?s record. [sic]
Standard #:	22VAC40-73-490-D
Description:
Plan of Correction:	1. The semiannual healthcare oversight will include listed specific names of those residents reviewed. 2. ED/Designee will review after semiannual oversight to ensure compliance. [sic]
Standard #:	22VAC40-73-870-B
Description:	Based on observations made during a tour of the building, the facility failed to ensure all buildings shall be well-ventilated and free from foul, stale, and musty odors. EVIDENCE: 1. The LI observed a strong foul odor resembling urine upon entering room #111 in the safe secure unit at approximately 10:43am on the date of inspection. 2. The LI visited room #111 again the same date after the noon medication pass and again noted the odor resembling urine.
Plan of Correction:	1. Room #111 has been deep cleaned. Resident?s clothing in her closet was washed and she has been provided with a new mattress. Room 111 will be painted and is scheduled to have new flooring. 2. Resident rooms are being deep cleaned. Furniture/mattresses found to have odors will be replaced. 3. Rounds will be conducted daily during the next 30 days by ED/MD/RCD/ARCD/Designee to ensure no further odors in #111 and throughout Special Care unit. 4. New and current staff will be educated to report any resident room with odors to housekeeping for cleaning and ED/designee will inspect for compliance. [sic]