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 3, 2022

Complaint Related: No

Technical Assistance:

To ensure a thorough understanding of standards, the licensing inspectors had a discussion with the licensee, the administrator and the director of nursing regarding standards 320-A, 440-A, and 325-C.

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on observation during medication cart audits, the facility failed to ensure that infection control policies that are consistent with the Centers for Disease Control and Prevention (CDC) recommendations were followed. EVIDENCE: The glucometer for resident 13, located in medication cart 1, and the glucometer for resident 14, located in the medication cart in the facility?s safe, secure unit, were not labeled with the resident?s name per CDC recommendations.
Plan of Correction:	I. The glucometer for resident 13, and the glucometer for resident 14, are labeled with the resident?s name per CDC recommendations II. The nursing director will audit all glucometer kits in the facility to ensure all devices are properly labeled. III. The nursing director and/or designee will audit all glucometer kits weekly to ensure they maintain proper labeling IV. Date of completion: June 1st, 2022
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure that physical examination reports for residents contained all required components. EVIDENCE: 1. The ?Report of Resident Physical Examination? for resident 7, dated 03/10/2022, indicated that the resident has allergies to Hydrocholorothiazide, Lisinopril, Singulair, Ambien, Diovan, Prevacid and Tape; however, the reactions to these allergies were not documented. 2. The ?Report of Resident Physical Examination? for resident 8, dated 10/21/2021, indicated that the resident has allergies to Donepezil and Gabapentin; however, the reactions to these allergies were not documented.
Plan of Correction:	I. Resident 7 & 8?s records include information on reactions to allergies II. The nursing director and/or designee will audit all resident records to ensure each with allergies includes information on reactions to allergies III. The nursing director and/or designee will review all new resident charts ongoing to ensure any with documented allergies also includes reactions to allergies IV. Date of completion: June 25th, 2022
Standard #:	22VAC40-73-640-A
Description:	Based on medication cart audit and document review, the facility failed to implement their medication management plan. EVIDENCE: 1. The facility?s medication management plan, reviewed and updated in August 2021, indicated the following on page 5 in regards to methods to prevent the use of outdated, damaged, or contaminated medications, ?all medications will be checked for expiration dates and/or any damages monthly when the medication administration records are reviewed during med change over.? 2. The record for resident 10 contained a physician?s order, dated 04/27/2022, for Humalog insulin inject 2 units subcutaneously with meals hold for BS (blood sugar) less than 100 and Lantus insulin inject 20 units subcutaneously every day. 3. One licensing inspector (LI) observed in medication cart 2 contained an open vial of Humalog and an open vial of Lantus for resident 10; however, neither vial contained a date of when the vials were opened by medication staff. This was also observed by staff 1 and 7 during on-site inspection on 05/03/2022. Once opened, Humalog insulin and Lantus insulin must be used within a specific time frame as indicated by their manufacturer.
Plan of Correction:	I. All medications for Resident 10 are properly labeled II. The nursing director and/or designee will audit all insulin medications to ensure each in use are properly labeled III. The nursing director and/or designee will audit all insulin medications weekly to ensure ongoing compliance IV. Date of completion: June 1st, 2022
Standard #:	22VAC40-73-680-M
Description:	Based on observation during medication cart audit, resident record review and staff interview, the facility failed to ensure that medications ordered for PRN (as needed) administration were available. EVIDENCE: The record for resident 9 contained a physician?s order, dated 04/06/2022, for Mapap Arthritis ER 650 MG take one tablet by mouth every 12 hours as needed for pain and Polyethylene Glycol 3350 powder as needed every day for constipation. Interview with staff 7 revealed that these medications were not in the facility for the resident during on-site inspection on 05/03/2022.
Plan of Correction:	I. All medications that are ordered for Resident 9 are onsite at the facility and available as prescribed. II. The nursing director and/or designee will complete medication cart audits on each cart to ensure all medications are available onsite as prescribed. III. The nursing director and/or designee will randomly audit medication carts monthly to ensure ongoing compliance IV. Date of completion: June 25th, 2022
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to ensure a physician?s order for oxygen therapy contained all required components. EVIDENCE: The record for resident 5 contained a physician?s order for oxygen, dated 04/28/2022, that does not include the source of the oxygen.
Plan of Correction:	I. The record for resident 5 includes the source of the oxygen for their oxygen order. II. The nursing director and/or designee will audit oxygen orders for those residents using oxygen to ensure each Includes the source of the oxygen III. The nursing director and/or designee will review all new oxygen orders to ensure ongoing compliance IV. Date of completion: June 25th, 2022
Standard #:	22VAC40-73-700-2
Description:	Based on observation during a tour of the physical plant, the facility failed to post ?No Smoking-Oxygen in Use? signs when oxygen therapy is provided. EVIDENCE: One licensing inspector (LI) observed an oxygen concentrator being used by resident 12 in his room through-out on-site inspection on 05/03/2022. The room did not contain a ?No Smoking-Oxygen in Use? sign.
Plan of Correction:	I. ?No Smoking-Oxygen in Use? signs are properly posted when oxygen therapy is provided. II. Administrator and/or designee will round the building on all current residents with the use of oxygen to ensure ?No Smoking? signage is properly posted. III. Administrator and/or designee will randomly round monthly to ensure proper signage is posted. IV. Date of completion: June 25th, 2022
Standard #:	22VAC40-90-30-B
Description:	Based on staff record review and staff interview, the facility failed to ensure that a sworn statement or affirmation was completed for all applicants for employment. EVIDENCE: The record for staff 5, date of hire 04/06/2022, did not contain documentation that a sworn statement or affirmation was completed. Interview with staff 6 confirmed this was accurate.
Plan of Correction:	I. The record for staff 5 contains a completed sworn statement or affirmation II. The administrative assistant will audit all current employee records to ensure each contains a completed sworn disclosure statement III. The administrative assistant and/or designee will review all new employee files to ensure ongoing compliance IV. Date of completion: June 25th, 2022