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: Oct. 29, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-80 COMPLAINT INVESTIGATION

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: 10/29/2024 8:50AM to 1:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/02/2024 regarding allegations in the areas of: personnel, admission, retention & discharge of residents, resident care & related services, and additional requirements for facilities that care for adults with serious cognitive impairments. Number of residents present at the facility at the beginning of the inspection: 39 Number of resident records reviewed: 5 Number of staff records reviewed: 1 Number of interviews conducted with residents: 2 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 some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: resident care & related services A violation notice was issued; any violation(s) not related to the complaint 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 #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on resident record review and resident interview, the facility failed to ensure the uniform assessment instrument (UAI) shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident?s condition. EVIDENCE: 1. The UAI for resident 3, dated 02/23/2024, indicates the resident is oriented to all spheres and indicates that the resident requires mechanical help and human help physical assistance with bathing. 2. During an interview with resident 3, resident 3 expressed to the licensing inspector (LI) that she does not need assistance with bathing and can bathe herself; therefore, indicating that her UAI is incorrect.
Plan of Correction:	This plan of correction is not construed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or the proposed administrative penalty (with right to correct) on the community. Rather, it is submitted as confirmation of our ongoing efforts to comply with all statutory and regulatory requirements. In this document, we have outlined specific actions in response to each allegation or finding. We have not presented all contrary factual or legal arguments, nor have we identified all mitigating factors. I. Resident #3 UAI has been updated to reflect current needs II. RCC or Designee will audit all current UAI for accuracy III. Administrator and/or designee will randomly audit UAI?s monthly for accuracy IV. Date of completion: 12/19/2024
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on resident record review and staff interview, the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. EVIDENCE: 1. During an interview with resident 3, resident 3 expressed to the licensing inspector (LI) that she does not need assistance with bathing and can bathe herself. 2. Staff person 1 revealed to the LI that she updated the resident?s ISP on 09/18/2024 with the statement that the resident will refuse showers and for staff to attempt multiple times to shower the resident; however, staff person 1 did not sign the updated ISP or get the resident to sign and date the updated ISP.
Plan of Correction:	This plan of correction is not construed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or the proposed administrative penalty (with right to correct) on the community. Rather, it is submitted as confirmation of our ongoing efforts to comply with all statutory and regulatory requirements. In this document, we have outlined specific actions in response to each allegation or finding. We have not presented all contrary factual or legal arguments, nor have we identified all mitigating factors. I. Resident # 1 ISP has been updated and signed by all parties II. Administrator and/or designee will audit all ISPs for accuracy and signatures III. Administrator and/or designee will randomly audit ISPs for accuracy IV. Date of completion: 12/19/2024
Standard #:	22VAC40-73-680-A
Complaint related:	Yes
Description:	Based on resident record review and staff interview, the facility failed to ensure staff who are licensed, registered, or acting as medication aides on a provisional basis as specified in 22VAC40-73-670 shall administer drugs to those residents who are dependent on medication administration as documented on the uniform assessment instrument (UAI). EVIDENCE: 1. The UAI for resident 1, dated 04/06/2024, indicates that the resident requires his medications to be administered/monitored by a lay person ? licensed practical nurse (LPN) or registered medication aide (RMA). The August 2024 medication administration record (MAR) for resident 1 contains the initials of staff person 1 administering xaerlto 20MG to resident 1 at 5:00PM 2. The UAI for resident 2, dated 02/05/2024, indicates that the resident requires her medications to be administered/monitored by a lay person ? LPN or RMA. The August 2024 MAR for resident 2 contains the initials of staff person 1 administering lorazepam 0.5MG and ensure liquid to resident 2 at 5:00PM. 3. The Virginia Department of Health Professions License Lookup website indicated on 10/28/2024 at 8:56AM, staff person 1?s RMA licensed was expired. Interview with staff person 1 confirmed this is accurate.
Plan of Correction:	This plan of correction is not construed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or the proposed administrative penalty (with right to correct) on the community. Rather, it is submitted as confirmation of our ongoing efforts to comply with all statutory and regulatory requirements. In this document, we have outlined specific actions in response to each allegation or finding. We have not presented all contrary factual or legal arguments, nor have we identified all mitigating factors. I. Staff Persons 1 license was renewed prior to inspection II. Administrator and/or designee will ensure all current staff license are active and up to date. III. Administrator and/or designee will randomly audit monthly to ensure compliance IV. Date of completion: 12/19/2024