VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Cedar Bluff
500 Clinic Drive
Cedar bluff, VA 24609
(276) 596-9750

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: April 22, 2026

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION ? 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS ? 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/02/2024 Begin: 12:00am End: 12:52pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. he evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. However, violation(s) not related to the (complaint(s)/self-report) but identified during the course of the investigation can be found on the violation notice. 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 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 #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on observations made during the medication cart audits and review of the facility?s medication management plan, the facility failed to implement and follow their own medication management plan. EVIDENCE: 1. The facility?s Clinical Policy and Procedure Manual-Virginia for Medication Policies #4 on page 50 states: ? counts are performed at the end of each shift or when the person responsible for medications changes. This includes breaks, mealtimes etc. Whenever a Med Aide leaves the floor and another Med Aide is responsible for meds, a complete count will take place by the person going off the cart and the person coming on the cart. 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.. If the quantity is verified, the off-going and on-coming Med Aides both sign the appropriate Controlled Substance Shift Count form 5.The ?Controlled Substance Change of Shift Log? did not have staff signatures/initials and were left blank on the following days in April 2024 on the 300 hall medication car for the 7pm-7am shift: 1st, 9th, 10th-22nd: off going and oncoming staff; 3rd: oncoming staff; 5th off going staff; 8th: off going staff. For the 7am-7pm shift: 1st: off going staff; 4th and 5th: off going staff and 8th-22nd off going staff and oncoming staff. 6. The ?Controlled Substance Change of Shift Log? did not have staff signatures/initials and were left blank on the following days in April 2024 on the 100 hall medication cart for the 7pm-7am shift: 1st:; 9th, 10th, 15th, and 17th -22nd ongoing and off going staff; 3rd and 10th oncoming staff; 11th, 12th, 13th, 14th and 16th-off going staff. For the 7am-7pm shift: 1st, 4th, 5th, 8th off going staff; 9th, 15th, and 17th-22nd oncoming staff and off going staff; and 11th-14th and 16th oncoming staff. 7. The ?Controlled Substance Change of Shift Log? did not have staff signatures/initials and were left blank on the following days in April 2024 on the safe, secure unit for the 7pm-7am shift: 4th, 12-th-14th, 19th-21st for off going staff and oncoming staff; 1st and 8th-11th and the 18th for off going staff. For 7am07pm for the off going staff on the 4th, the oncoming staff for the 7th-13th, 17th-21st.
Plan of Correction:	On 4/22/24, inservice training was completed with current med aides on the regulatory standard and Commonwealth Policy and Procedure on management of controlled substances to include completing and documenting of controlled substance counts to the Controlled Substance Shift to Shift Log. Post inservice, daily review was completed by RCD and ARCD to assure continued compliance with regulatory standard and policy and procedure. Moving forward the RCD, ARCD or designee will complete regular, random weekly reviews of the Controlled Substance Shift to Shift Log to assure continued compliance. [sic}