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: Sept. 3, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 09/03/2024 9:30AM until 11:30AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 08/08/2024 regarding allegations in the areas of: personnel and resident care and related services Number of residents present at the facility at the beginning of the inspection: 37 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also 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 facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-H
Description:	Based on resident record review and staff interview, the facility failed to ensure that the care and services specified in the individualized service plan (ISP) shall be provided to each resident. EVIDENCE: 1. The ISP for resident 1, dated 04/06/2024, includes an identified need that the resident has a foley and nephrostomy catheter and that direct care staff are to empty the catheter bags every shift and as needed. 2. Incident report provided to the licensing inspector (LI), dated 08/06/2024, states that staff person 1 informed staff persons 2 and 3 that when they got resident 1 up for breakfast on 08/06/2024 the resident had over 32 ounces of urine in his catheter leg bag, it was backed up into the tube and the straps were so tight they cut off circulation and left welts. 3. Staff person 2 informed the LI that staff person 4 was the staff person who was responsible for emptying the resident?s catheter leg bag during third shift on 08/05/2024 into 08/06/2024 and did not do so during their shift.
Plan of Correction:	I. Resident 1 needs ISP is being followed and needs are being met II. RCC and or designee will inservice nursing staff on how to read an ISP and compliaince III. The ED and the RCC will ensure all care needs are being met IV. Date of completion: 11/1/2024