VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Crystal Henson (276) 608-1067

Inspection Date:

Complaint Related: No

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on observations made during review of resident records, the facility failed to include a start date and/or expected outcomes dates for each service listed on the Individualized Service Plan (ISP) for three out of nine resident's Individualized Service Plans (ISP). 1. Resident #1 does not have any start dates or expected outcome dates listed for any of the 27 services listed on his ISP. 2. Resident #7 does not have start dates listed for any of the 21 services listed on her ISP. 3. Resident #9 does not have start any start dates or expected outcome dates listed for any of the 26 services listed on his ISP.
Plan of Correction:	ISPs reviewed and updated by ED, RMA. ISPs reviewed with family. ISP goals and start dates will be printed clearly on Yardi's assessment report. Executive Director will review for completeness. ISP trained staff. Training completed by DSS. [sic]
Standard #:	22VAC40-73-450-E
Description:	Based on observations made during the review of resident records, the facility failed to include a signature of the administrator or designee and the resident or legal representative for three out of nine residents on the Individualized Service Plan (ISP). EVIDENCE: 1. Resident #1 has an ISP dated 11/25/2021. There were no signatures on the ISP. 2. Resident #7 has an ISP not dated and did not include any signatures. 3. Resident #9 has an ISP dated 11/26/2021. There were no signatures on the ISP.
Plan of Correction:	ED has reviewed care plans with RP, Resident, POA. ED has gained signatures or reviewed virtually with family-verbal signature completed. ED wil review all care plans bi-annually with family members/POA and resident. After the care plan is reviewed the ED will document the verbal signature and/or gain the signature. [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on review of documentation and the medication cart audit, the facility failed to implement and follow their medication management plan to prevent the use of outdated, damaged, or contaminated medications. EVIDENCE: 1. The facility medication management plan states "all medications will be returned to the pharmacy or destroyed within 72 hours of discontinuance". 2. Resident # 10 is prescribed Lantus Solostar Subcutaneous Pen-injector 100 units inject 15 units sub-q at bedtime for diabetes mellitus II use within 28 days once opened. This insulin pen did not have an open date documented. 3. Resident # 1 was prescribed Ondansetron 4mg tablets which was discontinued on 10/23/2021 due to allergy. This medication was still on the medication cart on the day of inspection 01/11/2022.
Plan of Correction:	Medication removed from cart on the date of DSS inspection. Training completed with medication aides regarding disposal/returning D/C'd medications to the community. ARCD has been talked with weekly cart audits to ensure medication on the cart are current. [sic]
Standard #:	22VAC40-73-650-A
Description:	Based on observations made during the noon medication pass, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed or discontinued by the facility without a valid order from a physician or other prescriber. EVIDENCE: 1 Resident # 1 is prescribed Hydrocodone-Acetaminophen 10-325 mg oral tablet take four tablets by mouth four times daily for pain, Ropinirole HCL Oral 1 mg tablets take one tablet by mouth four times daily for Parkinson Disease, Diazepam 2 mg oral tablets take ? tablet (1mg) by mouth three times daily for anxiety, Gabapentin 100 mg oral capsules take 2 capsules (200mg) by mouth three times daily for nerve pain, Carbidopa-Levodopa 25-250 mg oral tablets take one tablet by mouth three times daily for Parkinson?s disease. The LI observed Staff # 2 administer these medication to Resident # 1 in Applesauce. There was no corresponding physician?s order to administer these medications in applesauce. 2. Resident # 10 is prescribed Carbidopa-Levodopa 25-100 mg oral tablets, take 1.5 tablets by mouth four times daily for Parkinson?s. The LI observed Staff # 2 administer this medication to Resident # 10 in Applesauce. There was no corresponding physician?s order to administer this medication in applesauce.
Plan of Correction:	New order sheets have been completed by MD. These include information orders of administering edications in applesauce, yogurt, or pudding. Order sheet will be reviewed and signed by-annually by the PCP. [sic]