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 5, 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 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-80 COMPLAINT INVESTIGATION.

Technical Assistance:

To ensure that the facility has a thorough understanding of standards, the licensing inspector and the Administrator had a discussion regarding standards 450 E, 530 B, 520 and 540.

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 05/05/2021 and concluded on 06/23/2021. A complaint was received by the department regarding allegations in the areas of administration and administrative services, personnel, admission, retention and discharge of residents, and 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. An exit interview was conducted with the Administrator on 06/23/2021, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the investigation. The evidence gathered during the investigation supported three of the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-50-A
Complaint related:	No
Description:	Based on document review, the facility failed to ensure that the statement prepared and provided to the prospective resident and his legal representative, if any, that discloses information about the facility included all required components. EVIDENCE: 1. The "Cardinal Senior Communities Assisted Living Facility Disclosure Statement" that was provided to Collateral 1 did not include 50-4. j. and l. and lacked Collateral 1's initials at the bottom of each page.
Plan of Correction:	I. The facilities disclosure statement has been updated to include sections outlined in 50-4-j and i. II. The administrator and/or designee will have all current residents, or their representatives, sign and initial the new updated disclosure statement III. The licensee will update the disclosure statement as needed in accordance with any future changes to regulatory requirements. IV. Date of completion: September 3rd, 2021
Standard #:	22VAC40-73-310-D
Complaint related:	No
Description:	Based on resident record review, the facility failed to review the uniform assessment instrument (UAI) prior to providing written assurance to the resident that the facility has the appropriate license to meet his care needs at the time of admission, give a copy of the written assurance to the legal representative, and keep a signed copy of the written assurance by the resident or his legal representative in the resident's record. EVIDENCE: 1. Resident 1 was admitted to the facility on 04/01/2021. 2. The written assurance in the record for resident 1 completed by staff 1, dated 03/25/2021, stated "One of our team members has completed the Virginia Uniform Assessment form that is required by the Department of Social Services for (resident 1)". 3. The UAI in the record for resident 1 was not completed until 03/31/2021 by staff 2. 4. The written assurance in the record for resident 1 did not contain a signature by the resident or Collateral 1 (legal representative). 5. Collateral 1 was not provided a copy of the written assurance.
Plan of Correction:	I. The facility completed two assessments (UAI?s) for resident #1 on 3/9/21 and 3/18/21 and prior to the issuance of the written assurance on 3/25/21. The facility has added a signature line on the written assurance form to ensure signature are obtained going forward. II. Administrator and/or designee will review UAI?s for new admissions to ensure proper completion prior to issuance of written assurance III. Date of completion: October 20th, 2021
Standard #:	22VAC40-73-325-C
Complaint related:	Yes
Description:	Based on resident record review, the facility failed to have documentation of interventions that were initiated to prevent of reduce risk of subsequent falls for residents who meet the criteria for assisted living care after they fell. EVIDENCE: 1. The uniform assessment instrument (UAI), dated 03/31/2021, assessed resident 1 as assisted living level of care. 2. The record for resident 1 contained documentation that the resident fell on the following dates: 04/07/2021, 04/09/2021 and 04/015/2021. 3. The record for resident 1 did not contain documentation of interventions that were initiated to prevent or reduce risk of subsequent falls.
Plan of Correction:	I. The facility has documentation of interventions that were initiated to reduce the risk of subsequent falls. II. The administrator and/or designee will review all recent incident reports involving falls to ensure interventions are being initiated to reduce the risk of subsequent falls III. The administrator will review all incident reports ongoing and sign off on the incident report acknowledging all requirements are being met IV. Date of completion: September 3rd, 2021
Standard #:	22VAC40-73-380-A
Complaint related:	No
Description:	Based on document review, the facility failed to ensure that all required personal and social information was obtained on all residents prior to or at the time of admission to an assisted living facility. EVIDENCE: 1. The document "RESIDENT - PERSONAL/SOCIAL DATA" for resident 1 does not include information on advance directives, Do Not Resuscitate (DNR) orders, or organ donation, current behavioral and social functioning and the telephone numbers for the two next of kin listed for resident 1.
Plan of Correction:	I. At time of admission, the facility requested information from resident 1?s responsible party on phone numbers for next of kin and advance directives, however, the responsible party was unable to provide this information. II. Administrator and/or designee will audit all current resident charts to ensure all personal and social information is complete to include an ?N/A? (not applicable) if it does not apply. III. Administrator and/or designee will review all new resident charts at admission to ensure all personal and social information is completed. IV. Date of completion: September 3rd, 2021
Standard #:	22VAC40-73-390-A
Complaint related:	No
Description:	Based on document review, the facility failed to ensure that at or prior to the time of admission, the written agreement/acknowledgment of notification included all required components. EVIDENCE: 1. The "Cardinal Senior Communities Assisted Living Agreement", signed by Collateral 1 on 03/05/2021, did not include 390-4 a., c., g., or k.
Plan of Correction:	I. The facilities written agreement has been updated to include sections outlined in 390-4- a,c,g, and k. II. The administrator and/or designee will audit all current resident agreements and update as needed to include the information outlined in 390-4- a,c,g, and k. III. The licensee will update the agreements as needed in accordance with any future changes to regulatory requirements. IV. Date of completion: September 3rd, 2021
Standard #:	22VAC40-73-390-B
Complaint related:	Yes
Description:	Based on interview, the facility failed to ensure that copies of the signed agreement/acknowledgment were provided to the resident and, as appropriate, his legal representative. EVIDENCE: 1. In a telephone interview with Collateral 1 (legal representative) on 06/03/2021, Collateral 1 stated that he did not receive a copy of the signed agreement/acknowledgment for resident 1.
Plan of Correction:	I. A copy of the signed agreement has been sent to the individual listed as collateral 1. II. Administrator and/or designee will ensure all new residents, or their legal representatives receive a copy of the written agreement after the agreement is complete. III. Administrator and/or designee will review all new resident files to ensure a copy has been provided and is documented accordingly. IV. Date of completion: September 3rd, 2021
Standard #:	22VAC40-73-400
Complaint related:	Yes
Description:	Based on interview, the facility failed to provide to each resident or the resident's legal representative, if one has been appointed, a monthly statement that itemizes any charges made by the facility and any payment received from the resident or on behalf of the resident during the previous calendar month and shall show the balance due or any credits for overpayment. EVIDENCE: 1. In a telephone interview with Collateral 1 (legal representative) on 06/03/2021, Collateral 1 stated that he has not received a monthly statement from the facility that itemizes any charges made by the facility and any payments received from the resident or on behalf of the resident during the resident's stay at the facility in April 2021.
Plan of Correction:	I. The facility is providing monthly billing statements of charges and payments received to all residents or their legal representatives. II. Administrator and/or designee will audit all current resident records to ensure monthly statements are being sent as required III. Administrator and/or designee will conduct a monthly review of resident accounts with bookkeeping to ensure ongoing compliance IV. Date of completion: October 20th, 2021
Standard #:	22VAC40-73-430-H-1
Complaint related:	No
Description:	Based on interview, the facility failed to provide a discharge statement at the time of a resident's discharge. EVIDENCE: 1. In a telephone interview with Collateral 1 (legal representative) on 06/03/2021, Collateral 1 stated that the resident has not been in the facility since 04/15/2021 and as of 06/03/2021 had not received the discharge statement.
Plan of Correction:	I. The responsible party for resident 1 did not inform the facility of their intention or request for discharge, however, the facility has sent a discharge statement based on the information they are able to obtain. II. The administrator and/or designee will ensure all residents who are discharged or their representatives are provided a discharge statement at the time of discharge III. The administrator and/or designee will randomly audit resident discharge files to ensure a copy of the discharge statement is included in the file IV. Date of completion: September 3rd, 2021
Standard #:	22VAC40-73-450-C
Complaint related:	No
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 ISP, dated 03/31/2021, showed that resident 1 required "safety checks (Q2 hour checks) due to the resident's inability to use call bell due to cognitive or physical impairment will monitor resident every two hours". Interview with staff 1 revealed that resident 1 was able to use the call bell. The ISP, dated 03/31/2021, showed that resident 1 attended "dialysis due to ESRD" and days attended were "Mon-Wed-Fri 12-4PM". Interview with staff 1 revealed that resident 1 only attended dialysis on Monday and Friday. The ISP, dated 03/31/2021, showed that resident 1 received physical and occupational therapy. Interview with staff 1 revealed that resident 1 did not receive physical and occupational therapy. Documentation from Collateral 3 showed that resident 1 received wound care; however, this was not addressed on the ISP. Interview with staff 1 verified that resident 1 was receiving wound care by Collateral 3.
Plan of Correction:	I. Current resident ISP?s are updated to address all identified needs II. The administrator and/or designee will audit all resident ISP?s to ensure that all identified needs are included III. The administrator and/or designee will randomly audit 2 resident ISP?s each month to ensure ongoing compliance IV. Date of completion: September 3rd, 2021
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s instruction. EVIDENCE: 1. The record for resident 1, admitted 04/01/2021, contained a signed physician?s order, dated 03/31/2021, for ?Midodrine 5 mg ? 1 cap, oral, TID, hold it if SBP > 130 mmhg?. The April 2021 medication administration record (MAR) for resident 1 showed the following blood pressure readings at 8AM: 04/02/2021; 143/89, 04/03/2021; 165/73, 04/05/2021; 168/72, 04/06/2021; 168/70, 04/07/2021; 148/80, 04/08/2021; 145/74, 04/09/2021; 136/74, 04/10/2021; 146/76, 04/11/2021; 136/70, 04/12/2021; 140/74, 04/14/2021; 138/70 and 04/15/2021; 136/72. The April 2021 MAR for resident 1 showed that Midodrine was administered to resident 1 at 8AM on all of these dates, for which the medication should have been held. The April 2021 MAR for resident 1 showed the following blood pressure readings at 2PM: 04/02/2021; 166/81, 04/03/2021; 165/73, 04/06/2021; 148/72, 04/08/2021; 156/72, 04/10/2021; 156/74, 04/11/2021; 148/72, 04/12/2021; 138/70, 04/13/2021; 138/74, 04/14/2021; 148/72 and 04/15/2021; 148/74. The April 2021 MAR for resident 1 showed that Midodrine was administered to resident 1 at 2PM on all of these dates, for which the medication should have been held. The April 2021 MAR for resident 1 showed the following blood pressure readings at 8PM: 04/02/2021; 159/79, 04/03/2021; 155/83, 04/04/2021; 178/81, 04/05/2021; 182/68, 04/06/2021; 156/71, 04/09/2021; 137/89, 04/12/2021; 152/78, and 04/14/2021; 140/74. The April 2021 MAR for resident 1 showed that Midodrine was administered to resident 1 at 8PM on all of these dates, for which the medication should have been held.
Plan of Correction:	I. All resident medications are being administered in accordance with the physician?s or other prescriber?s instructions. II. Administrator and/or designee will audit all current resident records to ensure each are receiving medications as prescribed. III. Administrator and/or designee will randomly audit two (2) resident records per month to ensure ongoing compliance. IV. Date of completion: October 20th, 2021
Standard #:	22VAC40-73-990-A
Complaint related:	No
Description:	Based on document review, the facility failed to ensure that the written plan for resident emergencies included all required components. EVIDENCE: 1. The facility's written plan for resident emergencies, "PLAN FOR RESIDENT EMERGENCIES AND PRATICE EXERCISE", does not contain the following sections: 990-A-2 and 4.
Plan of Correction:	I. The facilities written plan for resident emergencies includes information related to sections 990-A-2 and 4. II. Administrator and/or designee will complete a review of the ?Plan for resident emergencies and practice exercise? to ensure all required sections are included. III. Administrator and/or designee will randomly audit facility policies and procedures to ensure ongoing compliance. IV. Date of Completion: October 20th, 2021