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: April 21, 2021 , April 26, 2021 , May 13, 2021 and May 14, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 complaint inspection was initiated on 03/11/2021 and concluded on 05/14/2021. A complaint was received by the department regarding allegations in the area of resident care and related services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaints but identified during the course of the investigation can be found on the violation notice. This inspection was amended on 8/24/2021 to reflect the result of a review. The supplemental page was amended on 9/9/2021 to reflect the result of a review. This paragraph was added on 9/9/2021.

Violations:

Standard #:	22VAC40-73-70-C
Complaint related:	No
Description:	Based on document review, the facility failed to include all required information in an incident report. EVIDENCE: 1. The incident report regarding resident 1, dated 02/08/2021, lacked the phone numbers and addresses of witnesses to the incident, staff 2, 4, and 5.
Plan of Correction:	I. Cardinal Senior Communities has requested for a first step review to contest the findings for this violation
Standard #:	22VAC40-73-460-D
Complaint related:	Yes
Description:	Based on documentation and interviews, the facility failed to provide supervision of specialized needs of a resident, such as prevention of wandering off the premises. EVIDENCE: 1. The record for resident 1 contained a History and Physical, dated 12/19/2017, that showed the resident has mild dementia and a physician report, dated 11/26/2019, that showed the resident has progressive dementia. 2. The uniform assessment instrument (UAI), dated 12/11/2020, showed that resident 1 is disoriented to time and day, some of the time. 3. The record for resident 1 contained a physician order, dated 02/04/2021, for ?Wanderguard to be in place QD and checked QS?. Two anonymous staff interviews on 04/21/2021 and 04/02/2021 confirmed that resident 1 wore a Wanderguard. 4. In a telephone interview on 04/22/2021, staff 1 stated that when someone wearing a Wanderguard approaches a door, the door locks, and if the person wearing the Wanderguard still finds a way to get out, such as following someone else out, the alarm should go off. Staff 1 further stated that the system had been checked and it was working properly. 5. A facility incident report completed on 02/08/2021 stated, ?Staff conducting rounds @ approximately 2:15 ? 2:20 pm at that time was unable to locate rsd [1]. Staff had spoken with rsd [1] approximately 30 ? 40 mins prior to rounds in the common area.? 6. A police report from the Bedford Police Department, dated 02/07/2021 at 2:06 PM showed resident 1, age 86, was brought in to the police department by a member of the community, who found her wandering around at Elba?s (212 E. Washington Street, Bedford, Virginia). According to the police report, resident 1 said she was from Lynchburg and came to Bedford the previous night with friends but got lost. She could not remember her address and didn?t know her friends? phone numbers. The police report shows the temperature was 34 degrees Fahrenheit at the time resident 1 was brought to the police station. Police returned the resident to the facility after approximately half an hour, according the police report. 7. Google Maps showed the walking distance from the facility to the parking lot at 212 E. Washington Street, Bedford, VA is 1.4 miles and would take 28 minutes.
Plan of Correction:	I. Cardinal Senior Communities has requested for a first step review to contest the findings for this violation
Standard #:	22VAC40-73-560-F
Complaint related:	No
Description:	Based on interviews, the facility failed to make part of a resident record available for inspection to the department?s representative. EVIDENCE: 1. Discharge paperwork for resident 1 was requested prior to 4 PM on 05/13/2021 and as of 5:30 PM on 05/14/2021 it had not been made available to the licensing inspector. 2. In a telephone interview with staff 3 on 05/13/2021 at 3:56 PM, the staff member stated she was in charge since the owner and administrator were not in the building, and she had no access to resident 1?s record. 3. In a telephone interview with staff 2 on 05/13/2021, at 4:06 PM, the staff member stated the requested records could not be available on 05/13/2021 for inspection.
Plan of Correction:	I. Cardinal Senior Communities has requested for a first step review to contest the findings for this violation