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: Oct. 10, 2018

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Technical Assistance:

Technical Assistance was offered on this visit in regards to the activities calendar in this facility. Best practice would be for the facility to have a start and stop time of each activity specifying the length of each activity offered so residents could easily arrange their schedules around activities.

Comments:

Three licensing inspectors conducted a one day unannounced license renewal inspection on 10/10/2018. The inspection started at 9:15 am and concluded at 3:20 pm. The most recent inspection protocol was utilized and mandated standards were reviewed to determine compliance. A tour of the building and grounds was conducted; medication pass was observed; resident and staff files were reviewed along with a sample review of resident medications and physician's orders. Activities and lunch were observed and resident and collateral interviews were conducted. All required postings were observed to be in place. The facility is licensed to provide care to 74 residents. Resident rated at the residential and assisted level of care were observed to be in care as well as those in the secured unit for residents with serious cognitive impairments. At the time of the inspection, 70 residents were found to be in care. An exit meeting was conducted with three key staff members on 10/10/2018 and at that time the opportunity was given to find items that could not be located in the records. There are nine violations being cited as a result of this unannounced license renewal inspection. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within ten calendar days (11/04/2018)) of receipt. If you have any questions or concerns, please feel free to contact your licensing inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on documentation review, the facility failed to ensure the physical examination by an independent physician had all required questions answered. EVIDENCE: 1. Resident #2's physical dated 06/26/2018 failed to address his capability of medication self-administration. 2. Resident #8's physical dated 05/15/2018 failed to address her capability of medication self-administration. 3. Resident #1's physical dated 07/19/2018 does not address his capability of medication self-administration.
Plan of Correction:	Documentation was obtained from the physician for resident #1, 2, and 8 detailing whether the resident was capable of self administration of medications. All other admission history and physicals received after 02/01/18 were checked to ensure compliance. Resident Care Director will check all history and physical forms prior to admission to ensure required documentation is complete. Executive Director will audit 5 history and physical forms per month to ensure ongoing compliance. [sic]
Standard #:	22VAC40-73-380-A
Description:	Based on documentation review, the facility failed to ensure the personal and social information was fully obtained. EVIDENCE: Resident #8's physical dated 05/15/2018 failed to answer if she was allowed alcohol, tobacco, or if she had advanced directives.
Plan of Correction:	The social information for Resident #8 was obtained. All other admission history and physicals received after 02/01/18 were checked to ensure compliance. Resident Care Director will check all history and physical forms prior to admission to ensure required documentation is complete. Executive Director will audit 5 history and physical forms per month to ensure ongoing compliance. [sic]
Standard #:	22VAC40-73-440-A
Description:	Based on documentation review, the facility failed to maintain consistent information on the Uniform Assessment Instruments (UAI) for one resident in a sample of nine. EVIDENCE: 1. Resident #12's UAI dated 10/02/2018 states he is disoriented to some spheres, some of the time. Directly below this statement on the UAI it asks for spheres affected. The facility has "NONE" listed.
Plan of Correction:	UAI for Resident #12 was corrected. All other UAIs were checked to ensure accuracy and compliance. Executive Director or designee will audit a minimum of 5 UAI?s per month to ensure continued compliance. [sic]
Standard #:	22VAC40-73-450-C
Description:	Based on documentation review, the facility failed to address all needs listed on the Uniform Assessment Instrument (UAI) on the Individualized Service Plan (ISP) for one Resident out of the sample of nine. EVIDENCE: 1. Resident #12 has a UAI dated 10/02/2018 stating he needs human help in mobility; this includes mechanical assistance as well as physical assistance. This need is not addressed on the ISP for Resident #12 . 2. Resident #12 has a UAI dated 10/02/2018 stating he needs mechanical help only with toileting. On the ISP it states he is rated independent in toileting.
Plan of Correction:	Record reviewed to include identified need and what type of assistance staff are to provide on day of inspection. Community will continue to complete Preliminary ISP and Comprehensive ISP to ensure the individualized basic needs of the resident are adequately identified to include type of assistance needed to protect the resident?s health and safety. Executive Director will review the Preliminary ISP completed by the Resident Care Director or designee on the date of admission. Executive Director, Resident Care Director, and/or designee reviewed other ISPs to ensure compliance. Executive Director will complete random monthly audit of a minimum of 5 Comprehensive ISPs to ensure ongoing compliance. [sic]
Standard #:	22VAC40-73-650-E
Description:	Based on documentation review and staff interview, the facility failed to maintain all physician's orders chronologically in resident records. EVIDENCE: 1. Resident #13 has a physician's order for Nystatin Cream, that according to the Medication Administration Record (MAR) started on 10/03/2018. 2. Resident #13's physician's order the for the Nystatin was not available in her record. 3. Staff #6 had resident # 13's physician order for Nystatin Cream on her desk. 4. Staff #6 reported that she had physician's orders for approximately the last two weeks on her desk for multiple residents.
Plan of Correction:	Resident Care Director returned the physician orders to the resident?s chart. Resident Care Director was educated that if an order is needed for an extended period of time the order should be photocopied and the original maintained in the resident?s chart. Executive Director or designee will audit a minimum of 5 charts monthly to ensure there is a physician order in chronological order in the residents file for every medication order on the Medication Administration Record. [sic]
Standard #:	22VAC40-73-680-A
Description:	Based on resident interview, the facility failed to administer all medications to one resident that is rated dependent in medication administration on her Uniform Assessment Instrument (UAI). EVIDENCE: 1. Resident #13 has a physician's order with a start date on her Medication Administration Record (MAR) of 10/03/2018, for Nystatin Cream apply to vaginal area topically two times daily for itching for seven days. 2. Resident #13 asked Staff #3 when leaving Nystatin cream in her room to start putting the Nystatin cream in a used Vaseline container instead of the medication cup that staff were using so that the medication will not dry up before she uses it all. 3. Resident #13 is rated dependent in medication administration on her UAI dated 04/17/2018 and requires the assistance of a lay person to administer her medications.
Plan of Correction:	Resident Care Director will re-educate all RMAs and Nurses on adherence to the Rights of Medication Administration. Resident Care Director or designee will conduct a random medication pass audit a minimum of 2 times per month to ensure ongoing compliance and provide any necessary coaching on medication administration concerns. [sic]
Standard #:	22VAC40-73-680-C
Description:	Based on documentation review, the facility failed to administer medications to one resident according to the physician's specific instructions for scheduled dosing. EVIDENCE: 1. Resident #14 has a physician's order for Metoprolol 25mg 1 tablet by mouth every twelve hours for Hypertension. 2. Resident #14's Medication Management Record(MAR) shows the Metoprolol is administered at 10:00 am and 9:00 pm, only eleven hours apart.
Plan of Correction:	Resident Care Director obtained order same day as inspection to change the medication to BID. Licensed Nurse will continue to review all new medication orders in the Electronic Medication Administration Record and compare them to the physicians order prior approval to ensure ongoing compliance. [sic]
Standard #:	22VAC40-73-680-D
Description:	Based on documentation review and audit of the medication cart, the facility failed to administer medication in accordance with physician's orders and prescribers instructions. EVIDENCE: 1. Resident #5 had a physician's order for Diclofenac Gel 3% to be applied to both knees one time a day at bedtime for arthritis. The Medication Administration Record (MAR) also states the Diclofenac Gel 3% to be applied to both knees one time a day at bedtime for arthritis. The tube of medication is 1% instead of 3% and the instructions on the medication label stated that the medication was to be applied four times every day. A clarification order was sent to the facility during the inspection that the Diclofenac Gel is 1% and 4 grams is to be applied topically to bilateral knees daily at bedtime for arthritis pain. 2. Resident #3 has a physician's order for Asprin Chew Tab 81mg, one tablet by mouth one time a day for circulation. The MAR also states he is to receive Asprin Chew Tab 81mg, by mouth one time a day for circulation. Licensing Inspector observed Staff person #3 give Resident #3 the Asprin during the 10:00 am medication pass, but he swallowed it; he did not chew it as directed by the physician's order and the MAR.
Plan of Correction:	Resident Care Director will re-educate all RMAs and Nurses on adherence to the Rights of Medication Administration. Resident Care Director or designee will conduct a random medication pass audit a minimum of 2 times per month to ensure ongoing compliance and provide any necessary coaching on medication administration concerns. [sic]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the morning tour of the building, the facility failed to maintain all areas in good repair. EVIDENCE: 1. The Licensing Inspector observed the love seat in the common area located in front of the receptionist desk to have a large stain on the right cushion and on both arm rests. 2. Resident Room# 108 was observed to have large scuff marks on the bottom of the door. 3. The carpeting in front of the concierge desk in the front resident sitting area was observed to have a worn, ragged exposed seam.
Plan of Correction:	All areas mentioned were scheduled to be cleaned on 10/8/2018. Cleaning company completed several of the items mentioned, equipment broke during cleaning session, having to return on 10/12/2018 to complete job. Carpeting and flooring in front of the concierge desk has been scheduled to be repaired with company?s maintenance department. Scuff marks on identified room have been addressed and repaired. Direct care associates and housekeeping associates re-educated on completing maintenance repair requests when items are in need of repair. Executive Director, Maintenance Director, Resident Care Director, Assistant Resident Care Director, or designee will round a minimum of 2 times per day to ensure continued compliance. [sic]