VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cardinal House
1182 Eastside Highway
Waynesboro, VA 22980
(540) 943-1470

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: June 5, 2024

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/05/2024 08:30am-04:30pm 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: 31 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: The Licensing Inspector observed the residents during activities, meals and in their apartments. The following were reviewed at the time of inspection: Menus, activity calendars, fire drills, emergency drills, resident council minutes, dietician report, healthcare oversight. Additional Comments/Discussion: None 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure the physical examination was completed within 30 days preceding admission. Evidence: 1. Resident 4 admitted 1/3/2024 has a physical exam dated 1/23/2024.
Plan of Correction:	Effective immediately, the facility?s new policy for admission includes no admission without completion of DSS physician form or one containing the required information. All parties are being notified. Admin and Asst Admin will monitor for maintenance of future compliance.
Standard #:	22VAC40-73-350-A
Description:	Based on record review and staff interview, the facility failed to register with the Department of State Police to receive notice of the registration or reregistration of any sex offender within the same or a contiguous zip code area in which the facility is located, pursuant to ? 9.1-914 of the Code of Virginia. Evidence: 1. The facility failed to provide receipt of notification of the registration or reregistration of any sex offender in the area. 2. Staff 1 stated ?I don?t get those?
Plan of Correction:	The facility has registered with the dept of State Police on 6/5/24 and are receiving of sex offenders. The information will be maintained in a binder in the office. This information 6/30/24 location will be shared with residents or guardians at admission and annually. Documentation will be located in resident file
Standard #:	22VAC40-73-350-B
Description:	Based on record review the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. Evidence: 1. Resident 3 admitted 10/10/2023 has a sex offender search in their record dated 12/5/2023. 2. Resident 4 admitted 1/3/2024 has a sex offender search dated 1/22/2024.
Plan of Correction:	Effective immediately all sex offender status will be determined prior to admission. Asst Admin has primary responsibility with manager as back up to maintain future compliance
Standard #:	22VAC40-73-350-C
Description:	Based on record review and staff interview the facility failed to ensure that each resident or his legal representative is fully informed annually, that he should exercise whatever due diligence he deems necessary with respect to information on any sex offenders registered pursuant to Chapter 9 (? 9.1-900 et. seq.) of Title 9.1 of the Code of Virginia, including how to obtain such information. 1. The facility failed to provide documentation of annual receipt of information pertaining to the sex offender registry and how to obtain such information. 2. Staff 1 stated ?we haven?t done that?
Plan of Correction:	The facility has registered with the dept of State Police on 6/5/24 and are receiving of sex offenders. The information will be maintained in a binder in the office. This information 6/30/24 location will be shared with residents or guardians at admission and annually. Documentation will be located in resident file
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the Individualized Service Plan (ISP) includes all identified needs. Evidence: 1. Resident 1 has a Uniform assessment instrument (UAI) dated 1/5/2024 showing medication administered by lay person , the ISP dated 8/13/2024 does not include medication management. 2. Resident 2 has a UAI dated 10/4/2023 showing medication administered by lay person, the ISP dated 10/4/2023 does not include medication management. 3. Resident 3 has a UAI dated 3/18/2024 showing medication administered by lay person, the ISP dated 3/15/2024 does not include medication management. 4. Resident 4 has a UAI dated 1/18/2024 showing medication administered by lay person, the ISP dated 1/3/2024 does not include medication management.
Plan of Correction:	All medication is administered by staff. Medication administration will be added to services plans of all applicable residents. The Asst Admin assumes responsibility for corrections and future compliance. Back up is provided by manager and Administrator.
Standard #:	22VAC40-73-520-I
Description:	Based on direct observation the facility failed to ensure the current month's schedule is posted in a conspicuous location. Evidence: 1. Two licensing inspectors observed on the day of inspection, the activity calendar posted in the facility reflected the ?May 2023? schedule. 2. Staff 2 stated ?I thought I posted June? 3. Photo evidence taken
Plan of Correction:	he May 2023 was a typo as all other schedules maintained in the file for previous months were 2024. The May schedules was removed the day of the inspection and the June2024 which was behind it was left posted. All staff will be reminded to please notify office staff if noticing incorrect or outdated postings. The managing staff will continue to monitor during walk-thru?s and floor work to maintaining future compliance.
Standard #:	22VAC40-73-550-F
Description:	Based on direct observation during facility tour and staff interview, the facility failed to ensure the rights and responsibilities of residents are posted conspicuously in a public place. Evidence: 1. Two licensing inspectors did not observe the rights and responsibilities of residents posted in the facility. 2. Staff 1 stated during the interview ?It?s not posted?
Plan of Correction:	Manager copied the new version on date of inspection and posted. All staff will receive in service regarding making sure rights are always posted. Office staff will monitor to ensure compliance is maintained.
Standard #:	22VAC40-73-550-G
Description:	Based on record review the facility failed to ensure the rights and responsibilities of residents are reviewed annually with each resident and each staff person. Evidence: 1. Upon request the facility did not provide documentation of an annual review of the Rights and Responsibilities of residents for staff 5 (Hire date 4/9/2012) 2. The most current annual review of resident rights in Staff 5's record was dated 3/14/2022.
Plan of Correction:	An in service was held 4/5/23 on resident rights with staff 5 in attendance but admin logged attendance instead of securing signature. Staff 5 received training on 6/12/24. The signature page with resident rights used for residents and guardians will be used with all staff going forward. Asst. Admin will assume responsibility for monitoring and future compliance for residents and staff.
Standard #:	22VAC40-73-560-E
Description:	Based on direct observation, the facility failed to ensure all resident records are kept in a locked area. Evidence: 1. Two licensing inspectors observed an unlocked cabinet in the upstairs common area containing resident records. 2. Photo evidence taken.
Plan of Correction:	New lock was added to cabinet in question. Office staff will monitor to ensure remains locked and assume responsibility for maintaining future compliance. Signage has been added to cabinet indicating it is to be kept locked at all times
Standard #:	22VAC40-73-680-E
Description:	Based on record review and staff interview the facility failed to ensure medications were administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. Resident 2 has a physicians order dated 5/22/2024 that states ?Clindamycin HCL 300 MG capsule, take 1 capsule 3 times a day by oral route for 7 days? 2. The Medication administration record for Resident 2 indicates Clindamycin 300 MG capsule administered at 7pm on 5/22/2024, 7am, 1pm, 7pm on 5/23/2024, 7am and 7pm on 5/24, 7am, 1pm and 7pm on 5/25-5/27, and 7am and 1pm on 5/28. There is no record of administration for 1pm on 5/24 and no record of any administration on 5/29/2024. 3.Staff 2 stated ?the order was stopped too soon?
Plan of Correction:	Medication management regarding following all physician orders and accuracy of MARs will be reviewed with all applicable staff 6/24/24. Any corrections for EMAR should be reported to Admin staff and pharmacy immediately. Admin staff will monitor everyone for missed medications for the next 2 months then monthly at random times thereafter. Admin staff assumes responsibility for future compliance. Med errors identified will be reported to licensing and board of nursing
Standard #:	22VAC40-73-950-E
Description:	Based on record review and staff interview the facility failed to implement a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. Evidence: 1. Upon request the facility did not provide documentation of a semi-annual review of the emergency preparedness and response plan for all staff and residents. 2. Staff 1 stated during the interview ?we haven?t done that?
Plan of Correction:	Emergency preparedness was noted in the file for 11/8/23 with a following up Natural Disasters and preventing hypothermia which again included emergency preparedness response. The facility will repeat emergency preparedness review for all staff and resident?s week of 6/24/24 to comply with the violation. The admin and asst admin will also be more specific as it relates to future documentation of in services to ensure future compliance is maintained.
Standard #:	22VAC40-73-960-B
Description:	Based on direct observation the facility failed to ensure the fire evacuation drawing included all required information. Evidence: 1. Two licensing inspectors observed the fire evacuation drawing that did not include the secondary escape route, areas of refuge, or telephones. 2. Photo evidence taken.
Plan of Correction:	Fire evacuation plan contains four escape routes, 4 downstairs and 2 upstairs. Area of refuge is noted along with phones. Management staff will make any necessary changes if updates are made to building in the future. Last fire inspection was 3/28/24 with no violations.
Standard #:	22VAC40-90-40-B
Description:	Based on record review and staff interview, the facility failed to ensure a criminal history report was completed within required timeframe. Evidence: 1. Based on record review 9 of 11 new hire records did not have a criminal history report completed within 30 days of hire.
Plan of Correction:	The facility Administrator is working to be able to due background checks electronically. All new hires will have paperwork completed upon hired and sent until electronic system set up. Admin & Asst Admin assumes responsibility for maintenance of future compliance