VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cardinal Senior Communities
1350 Longwood Avenue
Bedford, VA 24523
(540) 586-0825

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: April 20, 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 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 and time the licensing inspectors were on-site at the facility for each day of the inspection: 04/20/2023 8:45AM until 1:15PM 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: 39 The licensing inspector 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: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: noon-time meal, medication pass, audit of medication cart 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-440-D
Description:	Based on resident record review, the facility failed to ensure that a uniform assessment instrument (UAI) for a private pay individual was completed as required. EVIDENCE: The UAI for resident 4, dated 04/14/2023, did not contain documentation about the resident?s behavior pattern on page 2.
Plan of Correction:	I. The UAI for resident 4 has been updated to reflect all identified needs II. The administrator and/or designee will review current resident UAI?s to ensure all information is complete III. The administrator and/or designee will randomly audit resident UAI?s to ensure ongoing compliance IV. Date of completion: June 1st, 2023
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure that identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The uniform assessment instrument (UAI) dated 04/01/2023 in the record for resident 7 has documentation that the resident requires physical and mechanical assistance with walking. The ISP dated 04/01/2023 does not address this identified need. Interview with staff 1 expressed that the UAI is correct and that resident 7 needs physical and mechanical assistance with walking. 2. The record for resident 5 has a signed Do Not Resuscitate (DNR) order dated 08/08/2022. The ISP dated 06/22/2022 is inconsistent as it has documentation that the resident is a full code.
Plan of Correction:	I. Residents #7 and #5 ISP?s have been updated to reflect all identified needs II. The administrator and/or designee will review all current resident ISP?s to determine any necessary changes III. The administrator and/or designee will randomly audit resident ISP?s to ensure updates are identified as changes occur IV. Date of completion: June 1st, 2023
Standard #:	22VAC40-73-550-G
Description:	Based on staff record review and staff interview, the facility failed to ensure that an annual review of resident rights was completed annually with all staff. EVIDENCE: 1. The record for staff 2, hired on 03/15/2021, has documentation that the last annual review of resident rights was completed on 02/10/2022. 2. The record for staff 5, hired on 10/09/2020, has documentation that the last annual review of resident rights was completed on 03/07/2022. 3. Interview with staff 1 confirmed this was accurate.
Plan of Correction:	I. Staff # 2 and # 5 have completed their annual review of resident rights II. The administrative assistant will review all employee records to determine that each have successfully completed the annual review of resident rights III. The administrative assistant will monitor ongoing to ensure that each staff member has completed their annual review of resident rights IV. Date of completion: June 1st, 2023