VIRGINIA DEPARTMENT OF SOCIAL SERVICES

CEDARFIELD Pinnacle Living
2300 Cedarfield Parkway
Richmond, VA 23233
(804) 474-8749

Current Inspector: Tamara Watkins (804) 662-7422

Inspection Date: Sept. 22, 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 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 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 renewal inspection was initiated on 9/22/20 and concluded on 9/25/20. The administrator was contacted by telephone to initiate the inspection.The administrator reported that the current census was 46. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed (3) resident records, (3) staff records, health and fire inspection reports, fire drills, dietician reports, as well as other documentation 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. Please complete a plan of correction and the date corrected or to be corrected for the violations cited on the violation notice and return to the Inspector within 10 days. You need to specify how the deficient practice will be or was corrected. Simply writing the word corrected is not acceptable. Your plan(s) of correction must contain: 1) steps to correct the non-compliance with the standard, 2) measures to prevent the noncompliance from occurring again and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on a review of resident records and accompanying documentation, an assessment meeting all the requirements of the standard was not completed prior to admission to a safe, secure environment. Evidence: Resident #2 was admitted to the secure unit of the facility on 8/24/20 the assessment provided for admission to the unit was the MMSE Mini Mental State Examination dated 8/24/20. It did not address all areas listed in the standard. Refer to VDSS Model Form-ALF Assessment of Serious Cognitive Impairment as a guide.
Plan of Correction:	Resident #2 was admitted to Memory Support on 8/24/20; before admission, verbal consent was granted by the resident's spouse and primary care physician as documented in the resident's electronic medical record. As this was a quick move from another level of care within our continuing care retirement community, the appropriate VDSS form stating this consent was not completed until a later date. The Admission Checklist for Memory Support has been updated to highlight the importance of having this specific form completed and placed in the resident's electronic medical record admission. The Administrator of Record, or designee, will ensure the Admission Checklist is completed before any future resident is admitted to Memory Support.