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: July 7, 2022

Complaint Related: Yes

Areas Reviewed:

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

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/07/2022 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 9:15am-1:45pm A complaint was received by VDSS Division of Licensing on 05/14/2022 regarding allegations in the area(s) of: supplies, neglect by facility staff, unable to meet resident needs and possible sexual assault. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. However, violation(s) not related to the (complaint(s)/self-report) but identified during the course of the investigation can 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

Violations:

Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on resident record review and review of the Medication Administration Record (MAR), the facility failed to have all items required by standards on the MAR. EVIDENCE: 1. On 05/21/2022, Resident #1 was prescribed Morphine Sulfate Oral Solution 20mg/ml, take 0.5ml every two hours for pain or shortness of breath. The replaced the previous order for Morphine .25ml to be given every four hours for pain or shortness of breath; this order was discontinued on 05/21/2022. 2. There was not start date on the May 2022 MAR for the 0.5ml Morphine every two hours for pain or shortness of breath.
Plan of Correction:	Pharmacy was contacted and new measurements put in place for MAR to be updated when orders are changed by on-call pharmacists. New orders will be checked by RCD or designee to ensure pharmacy has corrected new orders. [sic]