VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Cedar Bluff
500 Clinic Drive
Cedar bluff, VA 24609
(276) 596-9750

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: May 12, 2022

Complaint Related: No

Areas Reviewed:

2VAC40-73 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 ACCOMMODATIONS AND RELATED PROVISIONS ? 22VAC40-73 BUILDINGS AND GROUND ? 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 COMPLAINT INVESTIGATION ? 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Other Date: 05/12/2022 Start Time: 10:15am End Time: 10:45amThe the licensing inspector was on-site at the facility The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident) was received by VDSS Division of Licensing on 04/29/2022 regarding allegations of a resident VIRGINIA DEPARTMENT OF SOCIAL SERVICES DIVISION OF LICENSING PROGRAMS INSPECTION SUMMARY (ASSISTED LIVING FACILITY) Facility Name: Commonwealth Senior Living at Cedar Bluff Inspection Date: 05/12/2022 File #:1104314 DBA: Inspection End Date: 05/12/2022 ___________________________________________________________________________________________ Page 2 of 3 elopement. Number of residents present at the facility at the beginning of the inspection: 47 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: memory care area Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal B. Mullins, Licensing Inspector at 276-608-1067 or by email at Crystal.b.mullins@dss.virginia.gov Violation Notice Issued: Yes A copy of this document will be sent to the licensee/provider for signature. Inspector Name: Crystal B. Mullins Date Inspection Summary Issued: 6/5/20

Violations:

Standard #:	22VAC40-73-1040-B
Description:	Based on observations made during the tour of the safe and secure unit and documentation of a self-report, the facility failed to have protective devices on the bedrooms of residents with serious cognitive impairments to prevent the windows from being opened wide enough for a resident to crawl through. The protective devices on the window shall be in conformance with the Virginia Uniform Statewide Building Code. EVIDENCE: 1. Resident #1 was admitted to the safe and secure unit of the facility on 03/30/2022 due to a primary diagnosis of a cognitive impairment. 2. On 04/28/2022 at approximately 2:00pm, Resident #1 pushed her screen out of the window, raised the window in her room and was able to climb outside of the safe and secure unit into the edge of the facility parking lot. The resident was observed by the maintenance director as soon as she made her way out onto the ground. Staff were able to go outside in the parking lot immediately and keep Resident #1 under their supervision the entire time. The resident was not easily re-directed and decided she wanted to talk a walk and the staff member agreed to accompany her. The resident waked into the grocery store and then into a department store before 9-1-1 was called. The ambulance crew was able to re-direct Resident #1 into the ambulance. Resident #1 was transported to the ER for an evaluation and obtained placement for her; then declined the admission due cognitive status and was sent back to the facility around 2am.
Plan of Correction:	Windows on Memory Care were repaired to not tilt in for cleaning. All Windows are secured and unable for resident to open. Windows were fixed on the day of 04/2/2022. [sic]