VIRGINIA DEPARTMENT OF SOCIAL SERVICES

CEDARFIELD Pinnacle Living
2300 Cedarfield Parkway
Richmond, VA 23233
(804) 474-8749

Current Inspector: Tamara Watkins (804) 662-7422

Inspection Date: Nov. 29, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 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: Renewal Date(s) of inspection: 11/29/2022. Two licensing inspectors were on-site at the facility for each day of the inspection. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Type of inspection: Renewal Number of residents present at the facility at the beginning of the inspection: 40 Assisted Living and 20 Memory Care The licensing inspectors completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Additional Comments/Discussion: The evidence gathered during the initial inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The applicant has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to maintain future compliance with applicable standard(s) or law. If the applicant 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 should the facility be issued a license to operate. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Tamara Watkins, Licensing Inspector at (804) 662-7422 or by email at tamara.g.watkins@dss.virginia.gov Violation Notice Issued: Yes

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on a review of resident records the facility failed to ensure that residents have been assessed as having a serious cognitive impairment prior to placement in a secure environment. Evidence: There is no assessment present and maintained in the resident record to support placement in the memory care unit for resident #5. The resident has an admission date of 8/30/2021. It is unclear when the resident was placed in the secure unit. There is an approval for placement form dated 12/9/2021and an ISP dated 12/22/2021.
Plan of Correction:	Household Leader will ensure that Serious Cognitive Impairment forms are included in a packet alongside the History & Physical and TB Screening for the appropriate physician to complete within 30 days prior to admission. All consents will be scanned into resident charts within a timely manner to reflect compliance.
Standard #:	22VAC40-73-1100-A
Description:	Based on a review of resident records the facility failed to ensure approval by the POA or legal representative prior to placement in the secure unit. Evidence: Resident #6 was admitted to the memory care unit on 5/14/2021 but the approval for placement in the secure unit for resident #6 was not signed until 9/14/2021
Plan of Correction:	Household Leader is responsible for meeting with the resident and/or POA on the day of admission to complete a secure unit consent form with the understanding that the resident will live in a secure household. All consents will be scanned into resident charts within a timely manner to reflect compliance. Secure unit reviews will be conducted on a biannual basis to confirm the level of care remains appropriate.
Standard #:	22VAC40-73-320-A
Description:	Based on a review of resident records the facility failed to ensure that a risk assessment documenting the absence of tuberculosis in a communicable form was obtained 30 days prior to admission. Evidence: Resident #6 was admitted to the facility on 5/14/2021. The tuberculosis risk assessment is dated 5/15/2021. Resident # 3 was admitted to the facility on 3/21/2022. The tuberculosis risk assessment is dated 3/22/2022.
Plan of Correction:	Once a History & Physical form (that includes a tuberculosis screening) is given to the Household Leader, they will ensure the tuberculosis form has been completed and signed by an appropriate party. This applies to both individuals moving from outside of the community and those moving from a different level of care.
Standard #:	22VAC40-73-320-A
Description:	Based on a review of resident records the facility failed to ensure that physical examinations were obtained 30 days prior to admission. Evidence: Resident #6 has an admission physical examination dated 5/19/2021.The date of admission to the facility is 5/14/2021.
Plan of Correction:	Household Leader is responsible for ensuring individuals in the process of moving into the community have a copy of the History & Physical form and understand the 30-day prior policy. This applies to both individuals moving from outside of the community and those moving from a different level of care. All History & Physical forms will be scanned into resident charts within a timely manner to reflect compliance.
Standard #:	22VAC40-73-320-A
Description:	Based on a review of resident records the facility failed to ensure that residents admitted to the facility do not have any of the conditions or care needs prohibited by 22VAC40-73-310.H Evidence: The admission physical examination for resident #6 dated 5/19/2021 states ?needs continuous licensed nursing care? which is a prohibited condition.
Plan of Correction:	Household Leader is responsible for reviewing completed History & Physical forms to ensure potential residents are in fact appropriate for an assisted living level of care. If prohibited conditions are present, the physician will be contacted.
Standard #:	22VAC40-73-320-B
Description:	Based on a review of resident records the facility failed to obtain an annual risk assessment for tuberculosis for all residents. Evidence: The last tuberculosis risk assessment for resident #4 is dated 8/27/2021; 9/8/2021 for resident #6 and 5/15/21 for resident #3.
Plan of Correction:	Clinical leader in tandem with the community nurse practitioner audited all residents? annual TB screenings. Relevant screeningswere updated using the new DSS approved form.