VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cardinal Village
4621 Spotsylvania Parkway
Fredericksburg, VA 22408
(540) 898-1900

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: July 11, 2022 and July 12, 2022

Complaint Related: No

Areas Reviewed:

Administration and Administrative Services Personnel Staffing and Supervision Admission, Retention and Discharge of Residents Resident Care and Related Services Buildings and Grounds Emergency Preparedness Safe, Secure Environment

Comments:

Date of Inspection: July 11 and 12, 2022 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 34 Number of records reviewed and interviews conducted- 4 resident records and 7 staff records, 8 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during activities and care. The Licensing Inspector reviewed the following documentation during the inspection: resident council minutes, dietician report, activity schedules, healthcare oversight, menus and fire drills. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 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 #:	22VAC40-73-250-C
Description:	Based on staff record review and staff interview, it was determined that staff records failed to have documentation of required reports. Evidence: Staff C, D and E had no documentation of the original criminal record report.
Plan of Correction:	All staff records will have original criminal record reports as required. The Administrative staff will audit all staff records to ensure compliance.
Standard #:	22VAC40-73-250-D
Description:	Based on staff record review and staff interview, it was determined that staff records failed to have documentation of subsequent risk assessment for tuberculosis. Evidence: Staff F and G had no documentation in the record of a current tuberculosis risk assessment screening. Staff F's last screening was dated April 20, 2020. Staff G's last screening was July 27, 2020.
Plan of Correction:	All staff records will have the current risk assessment for tuberculosis as required. The Administrative staff will audit all records to ensure compliance.