VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Abingdon
860 Wolf Creek Trail NW
Abingdon, VA 24210
(276) 628-1621

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: Nov. 16, 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:

ype of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/16/2023 Begin: 9:30am End: 6:50pm 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: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 14 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: 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. 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 #:	22VAC40-73-1110-B
Description:	Based on resident record review, the facility failed to perform a six-month review of the appropriateness of one resident?s continued residence in the special care unit. EVIDENCE: 1. Resident #9 was admitted to the facility on 12/19/2022 and admitted to the special care unit on 12/20/2022. 2. The six-month review for Resident #9 to remain in the special care unit was not completed until 08/08/2023.
Plan of Correction:	ED/ARCD will complete review of current residents that have resided in special care unit greater than 6 months to assure they are current with review for appropriateness of continued residence. Each resident will be brought current. Moving forward a tracking system will be utilized to assure continued appropriateness for special care unit is reviewed at 6 months post move in-and at least annually per regulatory standards. documentation is completed every six months. [sic]
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the comprehensive individualized service plan (ISP) should include a description of needs and date identified based upon the Uniform Assessment Instrument (UAI). EVIDENCE 1. Resident #4 has a UAI completed on 08/08/2023 which documents resident #4 as exit seeking, agitated, and disoriented to place, time, and setting. The ISP for resident #4 completed on 08/08/2023does not address exit seeking behaviors, agitation, and disorientation for resident #4. 2. Resident #6 has a UAI completed on 04/18/2023 which documents resident #6 is disoriented to all spheres, at all times. The ISP for resident #6 completed on 04/18/2023 does not specify which spheres resident #6 is not oriented to.
Plan of Correction:	ARCD will update resident (4 & 6) UAI and ISP will be updated to reflect behaviors and orientation. ARCD/ED to complete an audit of current resident?s ISP and UAI to ensure orientation and behavior is addressed appropriately. [sic]
Standard #:	22VAC40-73-680-H
Description:	Based on review of resident records and medication administration records (MAR), the facility failed to document on the MAR at the time a medication was administered for one resident. EVIDENCE: 1. Resident #13 is prescribed Buspirone 5mg, one by mouth, three times daily; fish oil 1000mg, two by mouth, twice daily; Galantamine 12 mg, on tablet by mouth twice daily; Lantus 34 units sub-q daily; Melatonin 3mg, one-half tablet by mouth at bedtime; Metformin 1000mg, one tablet by mouth twice daily; Metoprolol Tartrate 25mg, one-half tablet by mouth twice daily. None of these medications were documented as administered on the November 2023 MAR for 10:00 pm on 11/11/2023. The LI and Staff #6 were able to verify through a medication count/audit that the medication was administered; just not documented. Resident #13 was not able to recall a night when he did not receive his prescribed medications.
Plan of Correction:	ED/ARCD will complete training with current LPN/RMA staff on documentation of administering medications. [sic]