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, 2020

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 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.

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 renewal inspection was initiated on 05/27/2020 and concluded on 05/28/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 41. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, fire inspection, health inspection, staff schedules, and sworn disclosures and criminal record checks for all newly hired staff since the last mandated inspection submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-210-F
Description:	Based on staff record review, the facility failed to ensure all staff had at least two hours of infection control and prevention training annually. EVIDENCE: 1. The record for staff 3, date of hire (DOH) 01/01/2017, contained documentation of only 1 hour of annual infection control and prevention training. Interview with staff 4 and staff 5 confirmed this was accurate. 2. The record for staff 2, DOH 06/15/2018, did not contain documentation of any annual infection control and prevention training. Interview with staff 4 and staff 5 confirmed staff 2 had not received annual infection control and prevention training.
Plan of Correction:	I. Administrator and/or designee will randomly audit (2) employee files each month to ensure compliance. II. Staff s #2 and #3 have completed the required amount of infection control training III. Administrator and/or designee will review all current employee files for compliance. IV. Administrator and/or designee will randomly audit (2) employee files each month to ensure compliance.
Standard #:	22VAC40-73-250-D
Description:	Based on staff record review, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility submitted the results of a risk assessment of tuberculosis (TB) documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. EVIDENCE: 1. The ?Virginia Department of Health Division of TB Control TB Risk Assessment Form (TB 512)? for staff 1, date of hire (DOH) 12/05/2019, did not include the day the assessment was conducted. The form showed a date of ?12/2019?. 2. The ?Virginia Department of Health Division of TB Control TB Risk Assessment Form (TB 512)? for staff 1; dated 12/2019, for staff 2; dated 06/15/2019, for staff 3; dated 01/01/2020 and resident 3; dated 02/12/2020 was completed by staff 4 who is a Licensed Practical Nurse (LPN). 3. The Virginia Department of Health states on the ?Division of Tuberculosis and Newcomer Health Tuberculosis Screening and Testing for Occupational Purposes? document that ?The TB risk assessment is a series of questions designed to determine an individual?s risk for either acquiring the TB bacteria in the body or of becoming ill with the disease, if infected. Questions may include information about current health status and recent illnesses, travel history, exposure to known individuals with TB disease, and selected medical diagnoses. While these questions may be asked by a licensed health care provider (MD, PA, NP,RN, LPN), consistent with Virginia professional practice acts, only physicians, physician?s assistants, nurse practitioners and registered nurses can assess risk for TB infection and/or disease based on the answers?. 4. Staff 4, who is a LPN, both asked the questions and assessed risk. The facility was not able to produce a written statement that staff 4 has oversight by a physician, physician?s assistant, nurse practitioner or registered nurse on day of the inspection when conducting TB assessments.
Plan of Correction:	I. Staff 1 received another TB assessment on 05/29/2020. Staff 1,2,3 TB assessment was completed by a licensed nurse under the supervision of a physician. A signed letter by the physician providing approval for the licensed nurse to conduct ongoing TB assessments is available. II. Administrator and/or designee will review all current employee files for compliance. III. Administrator and/or designee will randomly audit (2) employee files each month to ensure compliance.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that the Uniform Assessment Instrument (UAI) was updated whenever there was a significant change in the residents? condition. EVIDENCE: 1. The private pay UAI for resident 1, dated 01/06/2020, showed the resident needs supervision with dressing. The Individualized Service Plan (ISP) dated 10/21/2019, showed that resident 1 needs physical assistance with dressing. Interview with staff 4 revealed that the ISP is correct, and the UAI assessment is incorrect. Also, the UAI for resident 1 showed the resident needs no assistance with toileting. The ISP showed that resident 1 needs ?mechanical assistance and physical assistance with toileting?. Interview with staff 4 revealed that the ISP is correct, and the UAI assessment is incorrect. 2. The private pay UAI for resident 2, dated 11/16/2019, showed the resident needs mechanical help only with bathing. The ISP, dated 12/02/2019, showed that resident 1 ?requires staff supervision, in addition to mechanical assist of grab bars and shower mat?. Interview with staff 4 revealed that the ISP is correct, and the UAI assessment is incorrect.
Plan of Correction:	I. Resident 1 &2 records contains a up to date UAI II. Administrator and/or designee will review all records files for compliance. III. Administrator and/or designee will randomly audit charts monthly to ensure ongoing compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure that the Individualized Service Plan (ISP) addressed all of the identified needs. EVIDENCE: 1. The private pay Uniform Assessment Instrument (UAI) for resident 1, dated 01/06/2020, showed the resident needs mechanical and supervision human help with bathing. The ISP, dated 10/21/2019, showed that resident 1 ?requires staff physical assistance, in addition to mechanical assist of grab bars and shower mat. Interview with staff 4 revealed that the UAI is correct, and the ISP is incorrect. 2. The private pay UAI for resident 2, dated 11/16/2019, showed the resident needs no assistance with dressing. The ISP, dated 12/02/2019, showed that resident 2 ?currently needs supervision at times for dressing himself and has staff available if a need arises with dressing due to unsteadiness?. Interview with staff 4 revealed that the UAI is correct, and the ISP is incorrect.
Plan of Correction:	V. I. Resident 1 &2 records contains a up to date ISP VI. Administrator and/or designee will review all records files for compliance. VII. Administrator and/or designee will review all records files for compliance.
Standard #:	22VAC40-73-680-E
Description:	Based on resident record review, the facility failed to ensure that treatments ordered by a physician or other prescriber were documented and maintained in the resident?s record. EVIDENCE: 1. The record for resident 3 contained a physician?s order dated 02/26/2020 that stated ?may titrate oxygen to 4 liters per minute for management of shortness of breath; respiraton rate greater than 28. Return to 2.5 Liters after symptoms resolved. Call hospice for unmanaged symptom?. 2. The Individualized Service Plan (ISP), dated 02/12/2020, for resident 3 showed ?(resident) has an order for 5L of continuous of. Staff are to place o2 on and make sure that the tubbing is not tangled?. 3. ?Centra Hospice Hospice Progress Note? for resident 3, dated 02/24/2020, showed ?routine skilled nursing visit made today by hospice, patient sitting up in recliner, assessment performed, oxygen be @ 5 liters | min, educated staff that order is for 2.5 liters?. 4. The May 2020 Medication Administration Record (MAR) did not include this physician?s order for oxygen. Although the May 2020 Treatment Administration Record (TAR) included the physician?s order both the documented original date and date written were ?28-May-2020?. Interview with staff 4 revealed that the order had not been sent to the pharmacy to be recorded on the May 2020 TAR until 05/28/2020. 5. Neither the MAR nor the TAR for May 2020 included documentation of respiratory rates or the administration of oxygen. 6. On the date of inspection, 05/28/2020, TARs were requested for February 2020, March 2020, and April 2020 and had not been received as of 06/01/2020.
Plan of Correction:	I. Resident #3 records and MAR and TAR all match according to the physician orders. II. Administrator and/or designee will review all MARs and TARs for accuracy. Pharmacy will review as well. III. Administrator and/or designee will audit MAR and TARs five monthly to ensure ongoing compliance.