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: May 28, 2021

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

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 monitoring inspection was initiated on 05/27/2021 and concluded on 06/01/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 35. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, staff schedule, recent health care oversight, recent fire inspection, dates of the past three fire drills, recent dietitian review of special diets and recent pharmacy review submitted by the facility to ensure documentation was complete. To ensure that the facility had a thorough understanding of standards, the licensing inspector and the administrator had a discussion regarding standard 640-A. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1110-D
Description:	Based on resident record review, the facility failed to ensure that the review of the appropriateness of each resident?s continued residence in the special care unit was performed as required. EVIDENCE: 1. The ?REVIEW OF APPROPRIATENESS OF CONTINUED RESIDENCE IN SPECIAL CARE UNIT? document for resident 2, dated 12/06/2020, does not include documentation of consultation with any of the individuals listed on the form as required.
Plan of Correction:	I. Resident # 2?s record has been updated to reflect the individual whom with the consultation was completed. II. The administrator and/or designee will review all other resident records for those who reside on the special care unit and verify that all documentation of ?continued residence in special care unit? is complete. III. Administrator and/or designee will randomly audit resident charts monthly for those who reside on the special care unit to ensure ongoing compliance. IV. Date of completion: August 11th, 2021
Standard #:	22VAC40-73-1130-C
Description:	Based on document review and staff interview, the facility failed to ensure that during night hours when 22 or fewer residents are present, at least two direct care staff members are awake and on duty at all times in each special care unit and are responsible for the care and supervision of the residents. EVIDENCE: 1. The facility?s staff schedule for the dates 05/09/2021 through 05/27/2021 showed that only one direct care staff worked in the facility?s special care unit during the night shift; 10:30PM through 6:30AM. Interview with staff 4 confirmed that the facility?s night shift is 10:30PM through 6:30AM. 2. Interview with staff 4 revealed that there were four residents in the special care unit during this time period and that there was only one direct care staff working during the night shift on these dates.
Plan of Correction:	I. The facility has at least two direct care staff members awake and on duty during night hours in the special care unit. II. Administrator and/or Nursing Director will review and sign off on all direct care staff schedules to ensure appropriate staffing in the special care unit. III. Date of completion: June 11th, 2021
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure residents? individualized service plans (ISP) included all required components. EVIDENCE: 1. The ISP for resident 3, with an identified need date of 04/20/2021, showed that the resident receives physical therapy but does not include the agency that provides the physical therapy or the frequency of the physical therapy. Interview with staff 4 revealed that the agency is Collateral 1 and the frequency is one time per week. The ISP for resident 3, with an identified need date of 04/20/2021, showed that the resident needs mechanical help and supervision with mobility and ?supervised while using mechanical device while in/out of facility (cane, walker, rollator, wheelchair). Interview with staff 4 revealed that the resident only uses a wheelchair for mobility. 2. The ISP for resident 1, dated 12/07/2020, showed that the resident needs mechanical and physical assistance with mobility and ?physically assist of one and use of mechanical device in/out of facility (cane, walker, rollator, wheelchair)? and that the resident needs mechanical and physical assistance with walking and ?physical assist of one with ambulation, along with use of assistive device (cane/walker/rollator)?. Interview with staff 4 revealed that the resident did use a cane prior to being admitted to the facility but no longer uses a cane for mobility and walking.
Plan of Correction:	I. Resident # 3?s ISP is updated to include the agency providing therapy and frequency of therapy services. The ISP also reflects the correct device for mobility. Resident #1?s ISP has been updated to reflect the correct device for mobility, walking and ambulation. II. Administrator and/or designee will conduct ISP refresher training for staff that complete ISPs to include information on all required components. III. Administrator and/or designee will randomly audit five (5) ISPs monthly to ensure ongoing compliance. IV. Date of completion: August 11th ,2021
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and staff interview, the facility failed to ensure that individualized service plans (ISP) were reviewed and updated as the condition of a resident changes. EVIDENCE: 1. The April 2021 medication administration record (MAR) for resident 3 showed that the resident refused multiple medications on 04/04/2021, 04/06/2021, 04/12-13/2021 and 04/19/2021 and that resident ?spit out portion of meds? on 04/18/2021 and 04/12/2021. The May 2021 MAR for resident 3 showed that the resident refused multiple medications on 05/02/2021, 05/05/2021, 05/08-12/2021, 05/17/2021, 05/19/2021 and 05/22-23/2021. The ISP for resident 3, with an identified need date of 04/20/2021, showed ?description of needs ? Medication Management with Assistance? and ?Medication will be given per M.D. order and observed for side affects [sic]?. The ISP was not updated to reflect this significant change in resident 3?s condition.
Plan of Correction:	I. Resident #3?s ISP is updated to reflect change in condition regarding refusal of medications. II. Administrator and/or designee will review all resident MARs for possible changes in condition related to refusal of medications and ensure their ISPs are updated accordingly. III. Administrator and/or designee will randomly audit two (2) ISPs per month to ensure ongoing compliance. IV. Date of completion: August 11th, 2021
Standard #:	22VAC40-73-640-A
Description:	Based on document review, the facility failed to ensure that the medication management policy includes all required components. EVIDENCE: 1. The facility?s medication management policy, ?CARDINIAL [sic] SENIOR COMMUNITIES MEDICATION MANAGEMENT PLAN" does not include the facility?s standard dosing schedule.
Plan of Correction:	I. The medication management plan has been updated to include the facilities standard dosing schedule. II. Administrator and/or designee will review the medication management plan annually or as changes occur to revise as needed. III. Administrator and/or designee will randomly audit facility policies and procedures to ensure ongoing compliance. IV. Date of completion: August 11th ,2021
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to ensure a valid physician?s order for oxygen contained all the required components. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 04/28/2021, that showed ?Administer Oxygen at 2L/PM Via Nasal Cannula Continuously for Comfort/Shortness of Breath?. The order does not contain the oxygen source.
Plan of Correction:	I. The physician order for resident 1 has been updated to reflect the oxygen source. II. The administrator and/or designee will review all other resident records for those who require oxygen use and update the source as needed. III. Administrator and/or designee will review up to two (2) TARs and corresponding orders monthly for those using oxygen to ensure the order includes all necessary information. IV. Date of completion: August 11th, 2021
Standard #:	22VAC40-73-930-D
Description:	Based on resident record review and staff interview, the facility failed to ensure that for each resident with an inability to use a signaling device, the facility shall document rounds that were made, which shall include the name of the resident, the date and time of the rounds, and that staff member who made the rounds. EVIDENCE: 1. The individualized service plan (ISP) for resident 2, with an identified need date of 12/02/2020, showed ?Safety Check (Q2 hour checks) Due to resident?s inability to use call bell due to cognitive of physical impairment will monitor resident every two hours.? Interview with staff 4 confirmed that resident 2 cannot use a signaling device. The record for resident 2 only includes that rounds were made from 6:30PM through 6:30AM every two hours from 05/01/2021 through 05/26/2021 and does not include that rounds were made any other times during these days.
Plan of Correction:	I. Resident #2?s record is updated to specify a minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs. These rounds are documented according to the plan and include name of the resident, date, and time as well as the staff member completing the round. II. The administrator and/or designee will review all other resident records for those with an inability to use a signaling device and update as needed to specify a minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs. These rounds will be documented according to the plan. III. The administrator and/or designee will randomly review safety checks to ensure ongoing compliance with the plan. IV. Date of completion: August 11th, 2021
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to ensure that a criminal history record report was obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The records for staff 5, date of hire 01/18/2021 and staff 7, date of hire 02/01/2021, contained documentation that a criminal history record report was not received until 03/24/2021 for both staff 5 and 7. The record for staff 6, date of hire 08/26/2020, contained documentation that a criminal history record report was not received until 09/30/2020 for staff 6. The records for staff 8, date of hire 10/09/2020; staff 9, date of hire 11/02/2020; and staff 10, date of hire 03/15/2021 contained documentation that a criminal history record report was not received until 06/01/2021 for staff 8, 9 and 10.
Plan of Correction:	I. The facility will process criminal history record requests at time of hire to allow sufficient time for processing and receipt. II. Administrator and/or designee will review procedures of new employee orientation and onboarding and adjust process as necessary to ensure background checks are processed in accordance with this standard. III. Administrator and/or designee will randomly audit two (2) employee files monthly to ensure ongoing compliance. IV. Date of completion: August 11th,2021