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: April 18, 2023 and April 19, 2023

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 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

Technical Assistance:

Weekly Breakfast Menu to be Kept Current in Safe. Secure Unit Review of standards for Mixed Population

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An announced renewal inspection took place on 04/18/2023 from 8:10 am to 5:25 pm and 04/19/2023 from 8:08 am to 2:25 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 6 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 6 Observations by licensing inspector: Breakfast, Lunch and an activity were observed. A medication pass observation was completed for four residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and 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 inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-1110-B
Description:	Based on the record review the facility failed to ensure six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident?s continued residence in the special care unit. Evidence: 1. The record for resident #3 contains an admission and approval for placement in the safe, secure unit dated 11/17/21. The resident?s record does not contain documentation of a six month and annual review of the appropriateness of the resident?s continued residence in the special care unit. 2. The record for resident #4 contains an admission and approval for placement in the safe, secure unit dated 04/20/22. The resident?s record does not contain documentation of a six-month review of the appropriateness of the resident?s continued residence in the special care unit. 3. The record for resident #5 contain an admission and orientation to the safe, secure unit dated 09/28/21. The resident?s record contains a review of appropriateness for the special care unit dated 01/31/23, which is dated more than six months and annually after the resident?s admission date.
Plan of Correction:	Resident Files will be Audited for compliance. Any file found not compliant will address and correct at that time. Resident Care Director/ Assistant Resident Care Director/ designee to conduct Review of Continued Appropriateness of Admission to SCU 6 months after and at least annually thereafter. ED will conduct regular, random audits to assure continued compliance. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
Standard #:	22VAC40-73-120-A
Description:	Based on the record review the facility failed to ensure the training required in subsections B and C of this section shall occur within the first seven working days of employment. Evidence: 1. The record for staff #4, hire date 11/14/22, did not contain documentation of completion of staff orientation.
Plan of Correction:	Employee Files will be Audited for compliance. Any file found not compliant will address staff training and provide at that time. New hires will not begin working on the floor until orientation training is received by the Business Office Manager and approved by ED/designee. Business Office Manager will communicate with Executive Director in event new hire orientation training is not received in a timely manner. Business Office Manager/ Executive Director/ Designee
Standard #:	22VAC40-73-200-D
Description:	Based on the record review the facility failed to obtain a copy of the certificate issued or other documentation indicating that the person has met one of the requirements of subsection C of this section, which shall be part of the staff member?s record in accordance with 22VAC40-73-250. Evidence: 1. The record for staff #4, hire date 11/14/22, did not contain a certificate or documentation indicating staff #4 has met one of the requirements for direct care staff. 2. Staff #7 acknowledged staff #4 was hired as direct care staff with a personal care aide certification, however the certification was not in the staff record.
Plan of Correction:	Employee Files will be Audited for compliance. Any file found not compliant will address staff training and provide at that time. New hires will not start with community (to include initial onboarding) until all certifications for position are received by Business Office Manager and approved by ED/designee. Business Office Manager will communicate with Executive Director in event criminal history record report is not received in a timely manner. Business Office Manager/ Executive Director/ Designee
Standard #:	22VAC40-73-320-B
Description:	Based on the record review the facility failed to ensure a risk assessment for (TB) shall be completed annually on each resident as evidenced by completion of the current screening form published by the Virginia Department of Health or form consistent with it. Evidence: 1. The record for resident #2 contains a risk assessment for TB dated 04/16/21 and 01/28/23. The record does not contain documentation of a risk assessment for TB completed annually after 04/16/21. 2. The record for resident #3 contains a risk assessment for TB dated 11/16/21 and 01/28/23. The record does not contain documentation of a risk assessment for TB completed annually after 11/16/21. 3. The record for resident #5 contains a risk assessment for TB dated 09/17/21 and 01/28/23. The record does not contain documentation of a risk assessment for TB completed annually after 09/17/21.
Plan of Correction:	Resident Files will be Audited for compliance. Any file found not compliant will address and correct at that time. Resident Care Director/ Assistant Resident Care Director/ designee to conduct annual TB risk assessments annually, on a set month, and the Executive Director/designee will audit to verify this has been completed. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
Standard #:	22VAC40-73-430-H-1
Description:	Based on the record review the facility failed to ensure at the time of discharge, the assisted living facility shall provide to the resident, and as appropriate, his legal representative and designated contact person a dated statement. Evidence: 1. The record for resident #10, discharge date of 06/15/22, did not contain documentation of a dated discharge statement.
Plan of Correction:	Item was in Executive Directors Office at time of Inspection. Executive Director offsite at training. DSS Discharge Statement to be attached to discharged resident file in addition to nursing files and business office files moving forward. Additional Copy of DSS Discharge Statement to be retained in State Licensing Binder maintained in Executive Directors Office. Executive Director
Standard #:	22VAC40-73-450-A
Description:	Based on the record review the facility failed to ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed for the resident. The preliminary plan of care shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian. Evidence: 1. The record for resident #2, admission date of 11/01/22, contains a preliminary plan of care dated 11/13/22. The preliminary plan of care is not dated as completed on or within 7 days prior to the day of the resident?s admission. 2. Staff # 6 confirmed the admission date for resident #2 as 11/01/22. 3. Resident?s #6 preliminary plan of care dated 02/02/23, is not signed and dated by the resident or the legal guardian. 4.Resident?s #8 preliminary plan of care is not dated and is not signed and dated by the licensee, administrator/designee, resident or the legal guardian. 5. Resident?s #9 preliminary plan of care dated 04/14/23 is not signed and dated by the resident or the legal guardian.
Plan of Correction:	Resident Files will be Audited for compliance. Resident Care Director/ Assistant Resident Care Director and Resident Care Coordinator to complete ISP training. Moving forward, the Resident Care Director/ Assistant Resident Care Director/ designee to conduct and complete preliminary ISP no later than day of admission. Preliminary ISP will be provided to ISP for review and signature. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
Standard #:	22VAC40-73-450-C
Description:	Based on the record review the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission and shall include a description of identified needs and dated based upon the UAI. Evidence: 1. The record for resident #1, admission date 10/04/22, contains an ISP dated 02/05/23. The ISP is dated as completed more than 30 days after the resident?s admission date. 2. Resident?s #1 UAI dated 10/04/22 documents mechanical and human help needs for dressing, transferring, and eating/feeding. The resident?s ISP dated 02/05/23 does not include mechanical help needs for dressing and transferring. The ISP does not include mechanical and human help needs for eating/feeding. 3. The record for resident #2, admission date 11/01/22, contains an ISP dated 02/05/23. The ISP is dated as completed more than 30 days after the resident?s admission date. 4. Resident?s #3 UAI dated 12/01/22 documents mechanical and human help needs for dressing, and human help needs for walking. The resident?s ISP dated 12/01/22 does not include mechanical help needs for dressing and does not include the human help needs for walking. 5. The record for resident #6, admission date 02/02/23, contains an ISP dated 04/01/23. The ISP is dated as completed more than 30 days after the resident?s admission date. 6. The record for resident #7, admission date 12/21/22, contains an ISP dated 02/05/23. The ISP is dated as completed more than 30 days after the resident?s admission date.
Plan of Correction:	Resident Files will be Audited for compliance. Resident Care Director/ Assistant Resident Care Director and Resident Care Coordinator to complete ISP training Moving forward, Resident Care Director/ Assistant Resident Care Director/ designee to conduct and complete no later than 30 days after admission a comprehensive ISP with signature provide from resident or Power of Attorney. Comprehensive ISP will be provided to Executive Director for signature. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
Standard #:	22VAC40-73-450-D
Description:	Based on the record review the facility failed to ensure when hospice care is provided, the services provided by each shall be included on the ISP. Evidence: 1. The record for resident #5 contains a physician note dated 01/03/2023 for the resident to be referred to hospice. The resident?s record contains a Hospice Plan of Care completed by the hospice care organization dated 01/05/2023. 2. Resident?s #5 ISP is dated 11/08/22. The record does not contain an ISP documenting the services provided by the assisted living facility and the hospice care organization for the resident?s hospice care needs.
Plan of Correction:	Resident Files will be Audited for compliance. Any file found not compliant will address and correct at that time. Resident Care Director/ Assistant Resident Care Director and Resident Care Coordinator to complete ISP training Resident Care Director/ Assistant Resident Care Director/ designee to appropriately update the ISP to include delineation of care tasks that the hospice provider may be providing. Executive Director will complete regular, random audits of those residents receiving hospice services to assure compliance. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
Standard #:	22VAC40-73-450-E
Description:	Based on the record review the facility failed to ensure the ISP shall be signed and dated by the resident or his legal guardian. Evidence: 1. Resident?s #5 ISP dated 11/08/22 was not signed and dated by the resident or the legal guardian. 2. Resident?s #6 ISP dated 04/01/23 was not signed by the resident or the legal guardian. 3. Resident?s #7 ISP dated 02/05/23 was not dated by the resident?s legal guardian. 4. Resident #8?s ISP dated 12/13/22 was not signed by the resident or the legal guardian.
Plan of Correction:	Resident Files will be Audited for compliance. Any file found not compliant will address and correct at that time. Resident Care Director/ Assistant Resident Care Director/ designee to ensure ISP is reviewed with signature provide from resident or Power of Attorney once completed. Appropriate measures will be taken to secure signature in a timely manner to include email, general mail, etc. Attempts to obtain signature will be documented in resident file. ED will complete regular, random audits of resident files to assure signatures are being obtained. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
Standard #:	22VAC40-73-640-A
Description:	Based on observation the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated medications, and methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. Evidence: 1. During an observation with staff # 3 the following expired medications were observed on the medication cart: Amlodipine/Benazepril Capsules use by 04/11/23 for resident # 11; Coricidin Tablets expired 02/22/23 and Banophen Tablets expired 03/08/23 for resident # 12. 2. Staff # 2 confirmed resident #11 was administered on 04/19/23 the Amlodipine/Benazepril Capsules contained in the bottle labeled with a used by date of 04/11/23. The resident?s MAR indicates the resident was administered the Amlodipine medication the dates of 04/11/23-04/19/23. 3. The review of the facility?s ?Shift Change Controlled Substance Count Check? located in the safe, secure unit did not contain documentation of ?the off going and on-coming med aides? both signing the controlled substance count form on the following dates and times: 04/05/23 @ 7:00am and 3:00pm. 04/06/23 @ 3:00pm 04/07/23 @ 7:00am 04/08/23 @ 3:00pm 04/09/23 @ 3:00pm and 11:00pm 04/10/23 @ 3:00pm 04/11/23 @ 7:00am and 3:00pm 04/12/23 @ 3:00pm 04/13/23 @ 7:00am and 3:00pm 04/17/23 @ 3:00pm 04/18/23 @ 7:00am 4. The review of the facility?s ?Shift Change Controlled Substance Count Check? located in the assisted living care unit did not contain documentation of ?the off going and on-coming med aides? both signing the controlled substance count form on the following dates and times: 04/03/23 @ 3:00pm and 11:00pm 04/14/23 @ 7:00am 04/16/23 @ 7:00am and 3:00pm 04/16/23 @ 3:00pm 04/17/23 @ 3:00pm 04/18/23 @ 7:00am
Plan of Correction:	Narcotic Count Reconciliation will be Audited for compliance. Any items found not compliant will address and correct at that time. For the next 90 days, from 4/27/2023, the RCD or Designee will complete controlled substance counts with staff administering medications at a minimum of 3 times a week (One on each shift). The RCD or designee will then complete regular, random controlled substance counts with each shift at least monthly and as needed. RCD or Designee will conduct weekly audits on each medication cart to assure expired medications have been appropriately removed from the cart. The RCD/designee will complete medication pass audits with new medication staff prior to working alone on medication cart, periodically and as needed to meet regulatory standards. ED will conduct regular, random medication pass audits, to include controlled substance counts, at least semi-annually on current staff who administer medications to include RCD and RCC. New and current medication staff will be in-serviced on policy for signing on and off on Narcotic Count Reconciliation sheet. Form will be audited daily for signatures by Resident Care Director or Designee. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation the facility failed to ensure a medication cabinet, container, or compartment shall be used for storage of medications when such medications are administered by the facility. The storage area shall be locked. Evidence: 1. During observation with staff # 3 the following medication was observed on the window sill in the room of resident # 1: Azelastine HCI Nasal Spray. 2. Resident #1?s UAI dated 11/28/22 documents the resident?s medication is to be administered /monitored by a lay person or professional nursing staff.
Plan of Correction:	Resident Rooms will be Audited for compliance. Any resident room found not compliant will address and correct at that time. Families will be notified of any items found in residents? rooms that are non-compliant with regulation. Executive Director/ Designee will provide Education regarding the standard to Residents, Residents Families, and Staff. Executive Director/ Designee
Standard #:	22VAC40-73-670-1
Description:	Based on the staff record review the facility failed to ensure each person who administers medication shall be licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide. Evidence: 1. The record for staff #1 did not contain a license issued by the Commonwealth of Virginia to administer medications or documentation to include evidence of registration with the Virginia Board of Nursing as a medication aide. 2. The record for staff #1 contained a North Carolina Division of Health Service Regulation verification of passing a medication aide exam, dated 05/29/22. 3. During the medication pass observation staff #1 was observed to administer medications to residents #3 and #4.
Plan of Correction:	Employee Files will be Audited for compliance. Any file found not compliant will address staff training and provide at that time. New hires will not start with community (to include initial onboarding) until appropriate certifications and state license verification for position are received by Business Office Manager and approved by ED/designee. Business Office Manager will communicate with Executive Director in event criminal history record report is not received in a timely manner. Additional Copy of License Verifications to be retained in State Licensing Binder maintained in Executive Directors Office. Business Office Manager/ Executive Director/ Designee
Standard #:	22VAC40-73-680-E
Description:	Based on the record review the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. The documentation shall be maintained in the resident?s record. Evidence: 1. The record for resident #2 contains a physician order dated 02/27/23 documenting instructions to ?place c-pap machine on resident at bedtime. Remove in AM and clean in AM.? The resident?s record does not contain documentation of placement or removal of the c-pap machine. The record does not contain a physician order to discontinue placement and removal of the c-pap machine.
Plan of Correction:	Resident Files will be Audited for compliance. Any file found not compliant will address and correct at that time. Resident orders will be filed in resident chart chronologically by date, timely once appropriately executed. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
Standard #:	22VAC40-73-680-G
Description:	Based on observation the facility failed to ensure over-the counter medication shall remain in the original container, labeled with the resident?s name, or in a pharmacy-issued container, until administered. Evidence: 1. During observation with staff #3 the following over the counter medications were observed on the medication cart and did not contain a label of the resident?s name: Vitamin D-3 and Vitamin C.
Plan of Correction:	Medication Cart will be Audited for compliance. Any items found not compliant will address and correct at that time. The Executive Director will coordinate a Pharmacy Audit and Review to be conducted following unannounced visit. RCD or Designee will conduct weekly audits on each medication cart to ensure that medications are maintained in appropriately labeled medication container until administered to resident. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
Standard #:	22VAC40-73-720-A
Description:	Based on the record review the facility failed to ensure Do Not Resuscitate (DNR) Orders are included in the ISP. Evidence: 1. The record for resident #7 contains a DNR dated 02/20/23. The resident?s ISP dated 02/05/23 documents the resident as a Full Code. The ISP does not include documentation of the DNR order.
Plan of Correction:	Resident Files will be Audited for compliance. Any file found not compliant will address and correct at that time. Resident Care Director/ Assistant Resident Care Director and Resident Care Coordinator to complete ISP training Resident Care Director/ Assistant Resident Care Director/ designee to conduct and update to reflect appropriate changes as they occur. ED will conduct regular, random audits of resident files to assure Code Status is appropriately documented Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
Standard #:	22VAC40-90-40-B
Description:	Based on the onsite record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each staff person. Evidence: 1. The record for staff #8, hire date 07/11/22, contains a criminal history record report dated 04/18/23.
Plan of Correction:	Employee Files will be Audited for compliance. Any file found not compliant will address Criminal background check at that time. New hires will not start with community (to include initial onboarding) until criminal history record report is received by Business Office Manager and approved by ED/designee. Business Office Manager will communicate with Executive Director in event criminal history record report is not received in a timely manner. Business Office Manager/ Executive Director/ Designee