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: Dec. 5, 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: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/05/2022 Start: 9:30am End: 3:00 pm 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: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed:5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 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 #:	22VAC40-73-1070-B
Description:	Based on observation, 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 supervision. EVIDENCE: At approximately 10:45 AM, collateral 1 and collateral 2 found the spa in the memory care unit unlocked. Inside the spa room, collateral 1 and collateral 2 observed numerous shampoos, body washes, lotions, deodorants, cologne, toothpaste tubes, and a razor on the shelves throughout the shower. Lotions, body washes, and a bio hazard container containing disposable razors were found on the shelves next to the shower.
Plan of Correction:	What Has Been Done to Correct? Shower room door handle batteries were changed during licensure visit. How Will Recurrence Be Prevented? ED educated all staff on the importance of safety and harmful chemical storage in memory care. ED and Maintenance Director developed a schedule to ensure batteries are changed quarterly in all keypads that are securing harmful chemicals/ materials. Person Responsible: Executive Director; Maintenance Director Designee [sic]
Standard #:	22VAC40-73-320-A
Description:	Based on observations made during resident record review, the facility failed to include all information required by standards on the physical exam. EVIDENCE: 1 Resident #6 was admitted to the facility on 10/21/2022, her physical was completed on 12/20/2022. On the first page of the physical the selection of ambulatory or not ambulatory was not marked, and the general physical condition was left blank.
Plan of Correction:	What Has Been Done to Correct? New report of resident physical examination was reviewed and completed by Nurse Practitioner on 12/13/22. How Will Recurrence Be Prevented? RCD and ED will review all physical exam reports before residents are admitted to the facility. Person Responsible: Executive Director; Resident Care Director Designee [sic]
Standard #:	22VAC40-73-450-D
Description:	Based on record review, the facility failed to ensure that when hospice care is provided to a resident, the assisted living facility shall include the services provided on the individualized service plan (ISP). EVIDENCE: 1. The record for resident 7 contained documentation that the resident has been receiving hospice since 09/04/2022 for the following services: Skilled nursing once weekly for nine weeks; social work services once monthly for two months; home health aide twice weekly for eight weeks and then once weekly for one week; chaplain services once monthly for two months; however, the ISP for resident 7, dated 09/29/2022, did not contain indicate the need for hospice or the services and frequency to be provided.
Plan of Correction:	What Has Been Done to Correct? ISP updated to reflect hospice and frequency of services. How Will Recurrence Be Prevented? RCD and/or ED will review all ISPs of residents receiving hospice services to ensure details of services are defined in the ISP. ED and/or RCD will review the ISP of residents receiving hospice semi-annually and as needed to ensure all services are identified in the ISP. Person Responsible: Executive Director; Resident Care Director Designee [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on observation and record review, the facility failed to implement parts of its medication management plan. EVIDENCE: 1. The CSL Medication Management Plan, dated 06/10/2021, states the following regarding its methods to prevent the use of outdated, damaged, or contaminated medications, ?All Med Aides are to confirm expiration dates of medications during the medication pass.? 2. While completing an audit of the 200 & 400 hall medication cart, collateral 1, collateral 2, and staff 1 observed the following PRN medication for resident #11: MORPHINE 20MG/ML OS 30ML, ?TAKE THE CONTENTS OF 1 PREFILLED SYRINGE (0.25ML=5MG) BY MOUTH/UNDER TONGUE EVERY 1 HOUR AS NEEDED FOR PAIN, DYSPNEA, MOAN, GROAN, GRIMACING (CONTROL)?. The label also indicated the following ?DO NOT USE AFTER 10/30/2022?; however, this medication was still in the medication cart on the date of inspection. 3. Interview with staff 1 revealed that she did not realize that the syringes were expired. 4. The CSL Medication Management Plan, dated 06/10/2021, states the following regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes, ?2. The Med Aide on shift pulls the Controlled Substance Shift Count form and reports to the Med Aide who is coming on shift how many pills/capsules/etc. should be in each package. 3. The staff member coming on shift counts the medication in the container and verifies the quantity in the package. 4. ?the off-going and on-coming Med Aides both sign the appropriate Controlled Substance Shift Count form?. 5. The NARCOTIC COUNT SIGN OFF for the 200 & 400 hall medication cart was not signed by either oncoming or off-going staff on the following dates and shifts in November: On 11/15/2022, the form was not signed by off-going staff at 6PM nor oncoming staff at 6PM; on 11/16/2022, 11/17/2022, and 11/19/2022, the form was not signed by the oncoming staff at 6PM; on 11/20/2022, the form was not signed by the oncoming staff at 8PM; on 11/21/2022, the form was not signed by off-going staff at 6PM; on 11/25/2022, the form was not signed by the oncoming staff at 10PM; on 11/26/2022, the form was not signed by off-going staff at 8PM nor oncoming staff at 8PM; and on 11/29/2022, the form was not signed by oncoming staff at 6PM. 6. The NARCOTIC COUNT SIGN OFF for the 100 hall medication cart was not signed by either oncoming or off-going staff on the following dates and shifts in November: On 11/11/2022, the form was not signed by the oncoming staff at 6PM; on 11/21/2022, the form was not signed by the off-going staff at 6PM; on 11/22/2022, and the form was not signed off by the off-going staff at 6AM. 7. The NARCOTIC COUNT SIGN OFF for the 300 hall medication cart was not signed by either oncoming or off-going staff on the following dates and shifts in November: On 11/09/2022, the form was not signed by off-going staff at 6AM; on 11/12/2022, on 11/12/2022, the form was not signed by off-going staff at 6AM; on 11/12/2022, the form was not signed be oncoming nor off-going staff at 6PM; on 11/13/2022, the form was not signed by oncoming and off-going staff for all shifts; on 11/17/2022, the form was not signed by oncoming and off-going staff at 6PM; on 11/18/2022 and 11/19/2022, the form was not signed by oncoming and off-going staff for all shifts; on 11/28/2022, the form was not signed by oncoming staff at 6PM; and on 11/29/2022, the form was not signed by off-going staff at 6PM.
Plan of Correction:	Expired medication was removed from the cart while surveyors were present in the community. Order to D/C expired narcotic was obtained while surveyors present. CSL?s medication plan will be reviewed in detail with RMAs and LPNs. CSL?s cart audit forms have been reviewed with RCD, ARCD, and RMA Supervisor to ensure compliance with CSLs medication plan. ED and RCD have developed schedule to ensure carts are audited routinely. ED and RCD have reviewed with all RMAs and LPNs CSL?s policy on narcotic counts and narcotic signature sheets being completed at the beginning and end of the shift. Executive Director, Resident Care Director, Assistant Resident Care Director Designee will be responsible. [sic}
Standard #:	22VAC40-73-860-I
Description:	Based on observation, the facility failed to ensure that cleaning supplies and other hazardous materials are stored in a locked area. EVIDENCE: 1. At approximately 10:40 AM, collateral 1 and collateral 2 observed two cans of multi-surface cleaner and polish spray and Clorox bleach germicidal wipes under the sink off of the assisted living dining room. 2. At approximately 12:00 PM, collateral 1 and collateral 2 observed a housekeeping cart sitting in the middle of the hallway down from the staff lounge. The cart was unlocked and contained non-acid toilet bowl cleaner, Clorox bleach germicidal wipes, citrus air freshener, stainless steel cleaner and polish, and ant and roach plus germ killer.
Plan of Correction:	What Has Been Done to Correct? Items removed and secured during licensure visit. How Will Recurrence Be Prevented?ED will train all staff on the storage of cleaning supplies. ED/MD educated housekeeping staff on the storage and security of cleaning carts. Person Responsible: Executive Director; Maintenance Director or Designee. [sic]