VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Cedar Manor
1324 Cedar Road
Chesapeake, VA 23222
(757) 548-4192

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Jan. 19, 2023

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 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-80 COMPLAINT INVESTIGATION

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: An unannounced complaint inspection took place on 01/19/23 from 8:30 am to 5:20 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self report was received by VDSS Division of Licensing on 01/06/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 5 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: An observation of resident rooms, activities, and lunch was observed. The call bell system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation?s area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	Based on the onsite record review the facility failed to ensure the ISP (Individualized Service Plan) included a description of identified needs based upon the UAI (Uniform Assessment Instrument). Evidence: 1. The record for resident #1 contains a UAI dated 07/05/22 which documents a mechanical and human help need in the area of stairclimbing. The UAI includes a mechanical need for transferring. The ISP dated 07/12/22 does not include documentation of supports to address the needs for stairclimbing and transferring. 2. The record for resident #2 contains a UAI dated 02/10/22 which documents mechanical needs in the areas of dressing, toileting, and transferring. The ISP dated 02/10/22 does not include documentation of supports to address the mechanical support needs for dressing, toileting, and transferring. 2. The record for resident # 3 contains a UAI dated 09/19/22 which documents mechanical needs in the areas of dressing, toileting, transferring, walking, and wheeling. The ISP dated 09/19/22 does not include documentation of supports to address the mechanical support needs in the areas of dressing, toileting, transferring, walking, and wheeling.
Plan of Correction:	Resident Care Director (RCD) and Executive Director (ED) have evaluated and corrected care plans to ensure the UAI and ISP match and address each residents needs appropriately. UAIs and ISPs will continue be completed for new and current residents by community staff that are UAI and ISP certified per regulatory standard. Once the ISP is completed, for each resident per regulatory standard, the ED/designee will review the UAI against the ISP to assure they match and appropriately address current needs of that resident.