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: May 16, 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 22VAC40-73 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: 05/16/2024 Begin: 9:40am End: 4:20pm 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: 49 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:3 and 20 new hires Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 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 276-608-1967 or by email at crystal.b.mullins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-1
Description:	Based on observations made during the medication cart audits, the facility failed to follow blood glucose monitoring practices that are consistent with the CDC (Center for Disease Control and Prevention). EVIDENCE: 1. In the top drawer of the 300-hall medication cart the LI found one glucometer in a black bag, neither the bag nor the monitor was labeled with a resident?s name. Another glucometer was found laying in a white storage basket in the same drawer. The glucometer nor the white storage basket was labeled.
Plan of Correction:	Training has been completed with current RMA staff on appropriate labeling and storage of glucometers Current glucometers have been labeled and placed in appropriate storage. Moving forward, new glucometers will be labeled and placed in appropriate storage on the cart. [sic]
Standard #:	22VAC40-73-680-K
Description:	Based on observations made during the noon medication pass and the medication to MAR (Medication Administration Record) to physician?s order comparison, the facility failed to have a prescriber?s order which includes symptoms that indicate the use of the medicine, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist. EVIDENCE: 1. Resident #1 resides in the safe/secure unit and has a primary diagnosis of dementia. 2.Resident #1 has a signed physician?s order dated 03/19/2024 for the following medications: Acetaminophen 325mg tabs, take two tablets by mouth every six hours as needed for pain and Hydrocodon-APAP 5-325mg, take one tablet every 12 hours as needed. 3. During an interview with staff #1 and #2 licensed health care professionals are not available 24/7 in the facility to administer PRN medications.
Plan of Correction:	Existing PRN orders for residents in secure unit will be revised to specify the indicators of need for the PRN medications. Moving forward, new PRN orders for residents in secure unit will include specific indication for PRN medications. [sic]
Standard #:	22VAC40-73-690-F
Description:	Based on resident record review, the facility failed to maintain in writing the findings /recommendations of the medication review, the administrator was not advised of the said medication review, and it was not signed and dated and sent to the administrator within 10 days of the medication review for two residents. EVIDENCE: 1. Residents #2 and #3 did not have a current (within the last year) medication review maintained in their resident record at the facility on the date of the inspection.
Plan of Correction:	Review will be obtained for residents 2 and 3 and all other residents audited, and any missing reviews obtained. [sic]