VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cardinal Senior Communities
1350 Longwood Avenue
Bedford, VA 24523
(540) 586-0825

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Nov. 9, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 11/09/2020 and concluded on 12/08/2020. A complaint was received by the department regarding allegations in the areas of admission and resident care and related services. The owner was contacted by telephone to conduct the investigation. The licensing inspector emailed the owner and the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law; however, any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-40-B-12
Complaint related:	No
Description:	Based on review and staff interview, the licensee failed to ensure that at all times the department?s representative was afforded reasonable opportunity to inspect all of the facility?s records. EVIDENCE: 1. Staff 1 was contacted on 11/30/2020 to send the department?s representative meal consumption information for resident 1 for October and November, 2020. Staff 1 sent document ?Cardinal Senior Communities Record of ADLs?, which included meal consumption documentation, for resident 1 for November 2020 to the department?s representative. 2. Staff 1 informed the department?s representative that the ?Cardinal Senior Communities Record of ADLs? for resident 1 for October 2020 would be sent but this document has not been received for inspection as of 12/10/2020.
Plan of Correction:	II. The administrator of record at the time of the inspection was unable to produce the information requested in a timely manner. This administrator is no longer employed with Cardinal Senior Communities. III. Administrator and/or designee will ensure that at all time the departments representatives are afforded reasonable opportunity to inspect all the facilities documentation. IV. Date of completion: December 21st, 2020
Standard #:	22VAC40-73-580-E
Complaint related:	No
Description:	Based on document review, the facility failed to develop and implement a policy to monitor each resident for warning signs of changes in physical or mental status related to nutrition. EVIDENCE: 1. The document ?Cardinal Senior Living Change in Condition? provided by the facility on 12/01/2020 does not include how the facility will monitor each resident for warning signs of changes in physical or mental status related to nutrition.
Plan of Correction:	I. The facility has revised its Food Consumption Monitoring policy to more specifically address how to monitor each resident for warning signs of changes in physical or mental status related to nutrition. II. The administrator and/or designee will audit all other policies related to changes in condition to ensure they address how the facility will monitor each resident for warning signs of changes in physical or mental status. III. Administrator and/or designee will randomly audit company policies to ensure ongoing compliance. IV. Date of completion: March 1st, 2021
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1, admitted on 10/23/2020, contained a signed physician?s order, ?Order Reconciliation?, dated 10/22/2020 for polyethylene glycol 3350 17 gram oral powder packet to be administered one time a day for constipation. This medication was not included on the October and November 2020 medication administration records (MARs) for resident 1, nor did the record contain documentation that the medication had been administered. Interview with staff 1 on 12/10/2020 confirmed that polyethylene glycol had not been administered to resident 1. The record for resident 1 contained a note by ?Encompass Home Health?, dated 10/30/2020, that ?Pt found in her room, alert et (and) crying in pain. Pt states she has been in pain off et (and) on all night. Pt has had 0 BM X 3 days (with) decreased bowel sounds et (and) order written to give MOM (Milk of Magnesia) daily till successful BM, then QOD.? 2. The record for resident 1, admitted on 10/23/2020, contained a signed physician?s order, ?Order Reconciliation?, dated 10/22/2020 for metoprolol succinate ER 25 mg extended release 24 hr (12.5 mg) to be administered two times a day. The physician?s order showed ?Notes: BP and/or Pulse Hold: Diastolic Blood Pressure is < 60.00 Pulse is < 60.00 * Systolic Blood Pressure is < 100.00 BP and/or Pulse Hold: *Systolic Blood Pressure < 100 Hold; Diastolic Blood Pressure < 60 Hold; Pulse < 60 Hold ; HTN? The October and November 2020 medication administration records (MARs) for resident 1 showed that metoprolol succ ER 25 MG ?Take ? TABLET = (12.5MG) BY MOUTH 2 TIMES A DAY FOR HYPERTENSION? was administered to the resident daily at 8:00AM from 10/24/2020 through 11/02/2020 and daily at 8:00PM from 10/23/2020 through 11/02/2020. The record for resident 1 did not contain documentation that the resident?s blood pressure and pulse was taken by staff to determine whether the medication should be administered or held. Interview with staff 1 on 12/10/2020 confirmed that blood pressure and pulse was not taken by staff for resident 1 prior to administering metoprolol succinate ER 25 mg on these dates/times.
Plan of Correction:	I. All resident medications are being administered in accordance with the physician?s or other prescriber?s instructions. II. Administrator and/or designee will audit all current resident records to ensure each are receiving medications as prescribed. III. Administrator and/or designee will randomly audit two (2) resident records per month to ensure ongoing compliance. IV. Date of completion: March 1st, 2021