VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Cedar Manor
1324 Cedar Road
Chesapeake, VA 23222
(757) 548-4192

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: April 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 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

Technical Assistance:

Personal Data

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: An unannounced renewal inspection took place on 04/16/2024 at 08:38 am until 05:15 pm. 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: 84 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: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: Breakfast and an activity were observed. A medication pass observation was completed for four residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on the onsite record review, it was determined that the facility did not ensure the resident had within the 30 days preceding admission, a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: the date of the physical examination; results of a risk assessment documenting the absence of tuberculosis; a statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310-H. Evidence: 1. The record for resident #3, admission date, 06/29/23, contains a physical examination that does not include the date of the physical examination. 2. The record for resident #6, admission date 6/29/23, contains a risk assessment for TB dated 5/25/23. 3. Resident?s #6 physical examination includes a response of ?yes, requires continuous licensed nursing care.?
Plan of Correction:	What Has Been Done to Correct? Residents Physical Examination forms have been corrected to reflect appropriate needs of residents and free of Tuberculosis. How Will Recurrence Be Prevented? ED, RCD, or Designee will audit resident files to ensure proper documentation and ability to meet care needs of resident prior to admission. Person Responsible: ED, RCD, or Designee
Standard #:	22VAC40-73-325-B
Description:	Based on the onsite record review, it was determined that the facility did not ensure the Fall Risk Rating was reviewed and updated after a fall. Evidence: 1. The progress notes in the record for resident #1 documented falls that occurred on 12/15/23, 12/16/23, 12/18/23, 1/1/24, 1/8/24, 1/20/24, 1/25/24. There was no evidence of fall risk rating being completed after experiencing a fall. 2. The progress notes in the record for resident #2 documented falls that occurred on 3/9/24 and 3/15/24. There was no evidence of fall risk rating being completed after experiencing a fall. 3. The progress notes in the record for resident #4 documented falls that occurred on 11/3/23, 11/5/23, 11/26/23, 12/3/23. There was no evidence of fall risk rating being completed after experiencing a fall. 4. The progress notes in the record for resident #5 documented falls that occurred on 11/8/23 and 12/31/23. There was no evidence of fall risk rating being completed after experiencing a fall. 5. The progress notes in the record for resident #6 documented falls that occurred on 11/2/23, 11/18/23. There was no evidence of fall risk rating being completed after experiencing a fall.
Plan of Correction:	What Has Been Done to Correct? Resident files to be audited for Fall Risk Ratings and ensure Fall Risk Rating is accurate and up to date. How Will Recurrence Be Prevented? Fall Risk Ratings will be completed following each fall and placed in resident?s physical chart. Person Responsible: RCD, ARCD, or Designee
Standard #:	22VAC40-73-350-B
Description:	Based on the onsite record review, it was determined that the facility did not ensure that prior to admission, whether a potential resident is a registered sex offender and document in the resident's record that this was ascertained and the date the information was obtained. Evidence: 1.The record for resident #1 did not include a Sex Offender registry check prior to admission. 2. The record for resident #2 did not include a Sex Offender registry check prior to admission.
Plan of Correction:	What Has Been Done to Correct? Resident files to be audited for Registered Sex Offender form. How Will Recurrence Be Prevented? ED, SD, BOM, or Designee will audit new resident files to ensure proper documentation for Registered Sex Offender is reviewed prior to admission. Person Responsible: ED, SD, BOM, or Designee
Standard #:	22VAC40-73-410-A
Description:	Based on the onsite record review, it was determined that the facility did not ensure that upon admission, the assisted living facility provide an orientation for new residents and their legal representatives. Evidence: 1. The record for resident #1 did not contain an orientation for new residents to include emergency response procedures, mealtimes, and use of the call system.
Plan of Correction:	What Has Been Done to Correct? Resident files to be audited for Orientation. How Will Recurrence Be Prevented? ED or Designee to complete new resident Orientation and will audit resident files to ensure proper documentation and day of admission. Person Responsible: ED or Designee
Standard #:	22VAC40-73-450-C
Description:	Based on the onsite record review, it was determined that the facility did not ensure that the Comprehensive Individualized Service Plan shall be completed within 30 days after admission; and include a description of identified needs and date identified based upon the UAI, admission physical examination, and other sources. Evidence: 1. The record for resident #1, admission date 12/11/23, contains an ISP completed on 01/31/24, which is more than 30 days from admission. 2. The record for resident #8, admission date 02/05/24, contains an ISP completed on 03/27/24, which is more than 30 days from admission. 3. Resident?s #6 physician order, dietary oversite dated 09/27/23, and dietary oversite dated 12/08/23 documents a dietary need of, ?No Added Salt, cut foods prior to serving?. The resident?s ISP dated 02/01/24 did not include the dietary needs.
Plan of Correction:	What Has Been Done to Correct? Comprehensive Individualized Service Plan dates reviewed to ensure completion. How Will Recurrence Be Prevented? RCD or Designee will complete Comprehensive Individualized Service Plans prior to or on the 30th day. ED to review and audit resident files to ensure Comprehensive Individualized Service Plans are completed prior to or on the 30th day after admission. Person Responsible: RCD, ED, or Designee
Standard #:	22VAC40-73-450-E
Description:	Based on the onsite record review, it was determined that the facility did not ensure the Individualized Service Plan be signed and dated by the licensee, administrator, designee, and by the resident or his legal representative. Evidence: 1. Resident?s #6 ISP dated 02/01/24 was not signed and dated by the resident or the legal representative. 2. Resident?s #7 ISP dated 12/05/23 was not signed and dated by the resident or the legal guardian. 3. Resident?s #8 ISP was not signed by the resident or the legal guardian.
Plan of Correction:	What Has Been Done to Correct? Individualized Service Plans to be audited for signatures. How Will Recurrence Be Prevented? RCD or Designee will complete Individualized Service Plans and review Individualized Service Plan with resident and or resident?s legal representative. ED to review Individualized Service Plans have been reviewed and are signed prior to signature of ED. Person Responsible: RCD, ED, or Designee
Standard #:	22VAC40-73-450-F
Description:	Based on the record review the facility failed to ensure individualized service plans (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change in the resident?s condition. Evidence: 1. Resident?s #1 physician order dated 02/21/24, includes ?change diet to puree as tolerated.? Resident?s #1 physician order dated 2/22/24 includes ?Aspiration precaution due to patient choking episode on 1/23/24?. The resident?s ISP dated 01/31/24 was not updated to reflect the change in dietary need, and the aspiration precaution.
Plan of Correction:	What Has Been Done to Correct? Comprehensive Individualized Service Plan change in condition reviewed to ensure completion. How Will Recurrence Be Prevented? RCD or Designee will complete Individualized Service Plans updates with each significant change in condition. ED to review and resident files to ensure Individualized Service Plans are updated with change of condition. Person Responsible: RCD, ED, or Designee
Standard #:	22VAC40-73-660-A
Description:	Based on observation, it was determined that the facility did not ensure that medications shall be stored in a manner consistent with current standards of practice and the storage area shall be locked and the individual responsible for medication administration shall keep the keys to the storage area on his person. Evidence: 1. During a tour of the facility, the Licensing Inspectors observed that the medication cart located on the second floor was unlocked and unstaffed. 2. Staff #6 acknowledged that the medication cart on the second floor was unlocked and unstaffed.
Plan of Correction:	What Has Been Done to Correct? RCD and ED provided education to Medication Aide on regulation. How Will Recurrence Be Prevented? RCD, ED, or Designee will complete a Medication Management Plan review with all Medication Aides on staff. All Department Heads to periodically round community to ensure medication carts are locked and secure. Person Responsible: RCD, ED, or Designee
Standard #:	22VAC40-73-680-D
Description:	Based on the onsite record review, it was determined that the facility did not ensure medications shall be administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. Resident?s #7 physician order dated 12/05/23, and the medication administration record for April 2024 includes the following: ?Vitamin B1 50 mg, take 1 tablet by mouth every day.? During the medication pass observation, staff # 4 administered a Vitamin B1 100mg tablet to resident #7, however this is not the prescribed dosage according to the resident?s physician order. 2. Resident?s #7 physician order dated 03/23/23, and the medication administration record for April 2024 includes the following: ?Vitamin D3 1000IU, take 1 tablet daily.? During the medication pass observation, staff # 4 administered a Vitamin D3 5000IU to resident #7, however this is not the prescribed dosage according to the resident?s physician order.
Plan of Correction:	What Has Been Done to Correct? Medication dosage has been corrected. How Will Recurrence Be Prevented? RCD or designee to audit resident med cart for non-pharmacy OTC to ensure correct dosage. RCD or ED to provide education to families on pharmacy dispensing medication due to safety. Person Responsible: RCD, ED, or Designee
Standard #:	22VAC40-73-940-A
Description:	Based on a review of documentation and interview, it was determined that the facility did not ensure that an annual inspection is conducted by the appropriate fire official to comply with the Virginia Statewide Fire Prevention Code (13VAC5-51). Evidence: 1. The most recent fire inspection completed at the facility was dated 3/10/23. 2. Staff #6 confirmed that the annual fire inspection had not been completed.
Plan of Correction:	What Has Been Done to Correct? Fire Inspector called while Licensing Inspector onsite to schedule inspection. How Will Recurrence Be Prevented? ED to audit State binder and ensure all scheduled inspections are completed or scheduled prior to expiration date. Person Responsible: ED, MD, or Designee