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: June 7, 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

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: 06/07/2023Begin: 9:30am End: 3:04pm 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: 44 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 15 Number of staff records reviewed: 17 Number of interviews conducted with residents: 6 Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: 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 Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1100-C
Description:	Based on resident record review, the facility failed to obtain the written approval of one of the allowable persons; (in order of priority) prior to placing a resident with a serious cognitive impairment due to dementia in a safe, secure environment and retain the documentation in the corresponding resident file. EVIDENCE: 1. Resident #13 was admitted to the special care unit on 06/14/2022. Resident #3 was admitted to the special care unit on 01/31/2023. Resident #2 was admitted to the special care unit on 07/11/2019 According to the form ?Approval for Placement in Special Care Unit?, the facility did not document why written approval was not obtained from the allowable persons in the order or priority (self, guardian or legal representative, spouse, adult child, parent, adult sibling, adult grandchild, adult niece or nephew, aunt or uncle, independent physician) 2. An independent physician signed for the placement for resident #13 on 06/14/2022.; for resident #3 on 01/31/2023; and on 07/11/2019 for resident #2. 3. The explanation of the previous choices (self, guardian or legal representative, spouse, adult child, parent, adult sibling, adult grandchild, adult nice or nephew, and aunt or uncle were not documented as to why written approval not obtained from each individual higher on the list of priority.
Plan of Correction:	Audit will be completed of current residents residing in special care unit to assure there is appropriate explanation as to why approval was not obtained in order of priority. Approval for Placements will be updated as appropriate. Moving forward, the Executive Director/designee will document to Approval of Placement the explanation of why written approval was not obtained from the allowable persons in the order of priority. The RCD/designee will review prior to placing from in resident file to assure explanation is available and will update if warranted. [sic]
Standard #:	22VAC40-73-1110-B
Description:	Based on resident record review, the facility failed to complete the six-month review (and annually thereafter), of the appropriateness of a resident?s continued placement in the special care unit. EVIDCENCE: 1. According to an interview with staff #4, and the documentation for approval of placement in a special care unit, resident #13 was admitted to the special care unit of the facility on 06/14/2022. 2. The six-month review for resident #4 was performed on 03/14/2023. This date exceeds the allowable time for review. 3. Resident #3 was admitted to the special care unit on 07/10/2019. 4. The facility completed the ?Review for Appropriateness of Continued Residence In Special Care Unit? for Resident #3 on 03/01/2022 and 03/14/2023.
Plan of Correction:	Audit completed of current special care unit resident files to assure Review of Appropriateness for Continued Residence is completed and available for those residents that have lived at community greater than 6 months. Moving forward the RCD/designee will assure that the Review of Appropriateness for Continued Residence is completed 6 months post move-in and at least annually to assure continued compliance with regulatory standard. For the next 60 days, until 9/1/2023, the ED/designee will complete regular, random audits of files for those living in special care unit to assure appropriateness has been completed per regulatory standard. [sic]
Standard #:	22VAC40-73-290-B
Description:	Based on staff interviews and observations made during the tour of the building, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge, as provided for in 22VAC40-73-290-A, in a place in the facility that is conspicuous to the residents and the public. EVIDENCE: 1. The LI was unable to locate the name of the current on-site person in charge during the tour of the facility. 2. Staff confirmed this information was located near the employee time clock, but not in a place in the facility that is conspicuous to the residents and the public.
Plan of Correction:	A new sign is updated daily to reflect the current person in charge and is in a location that conspicuous to residents and the public. [sic]
Standard #:	22VAC40-73-320-A
Description:	Based on observations made during resident record review, the facility failed to ensure all items required by the standards were included on the physical prior to admission to the assisted living. EVIDENCE: 1. Resident #1 was admitted to the facility on 01/08/2020; physical was completed on 01/03/2020. The physical lists allergies as: penicillin, Bactrim, cortisone/steroid, ds/sulfa drugs. There were no reactions listed. 2. Resident #2 was admitted to the facility on 07/11/2019; physical was completed on 06/19/2019. The physical lists allergies as: promethazine. There were no reactions listed. 3. Resident #4 was admitted to the facility on 04/07/2023; physical was completed on 04/06/2023. The physical lists allergies as: penicillin, no reaction(s) were listed. 4. Resident #3 was admitted to the facility on 02/01/2023; physical was completed on 01/31/2023. On page one of the physical, the general condition was left blank by the physician.
Plan of Correction:	1. Allergy reaction added to physical. 2. Allergy reaction added to physical. 3. Allergy reaction added to physical. 4. General condition added to H&P by physician. Report of Physical Examination?s will be reviewed for current residents and updated as appropriate. Moving forward, the Report of Physical Examination will be reviewed at move-in to assure appropriate completion by the physician. Corrections will be obtained as warranted. [sic]
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review, the facility failed to complete the UAI as required by 22 VAC 30-110 for private pay individuals. EVIDENCE: 1. Resident #4 has a private pay UAI completed on 04/07/2023, this UAI documents medication administration as a need. The box ?by professional nursing staff? is checked, this is incorrect, this facility uses medication aides to administer medications and should have checked ?administered by layperson?. 2. Resident #3 resides in the safe/secure unit. The private pay UAI was completed on 03/03/2023 and documents this resident does not need assistance with meal prep and money management.
Plan of Correction:	Audit completed of current resident files to assure that UAI appropriately addresses ?medication administration? being ?administered by lay person?. Moving forward the RCD/designee will assure that the UAI appropriately addresses that medications are ?administered by lay person?. The ED/designee will review, prior to signing, to assure UAI addresses as per regulatory standard. [sic]
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to include all needs identified on the UAI on the comprehensive ISP. EVIDENCE: 1. Resident #4 has a UAI completed on 04/07/2023 and an ISP completed on 05/09/2023. The UAI documents resident #4 needs assistance with eating/feeding and walking/mobility; but the ISP does not address this need.
Plan of Correction:	Review of current UAIs/ISPs will be completed by 8/1/2023 to assure that UAIs/ISPs match in assessed care and needs. Moving forward the RCD/designee. that is appropriately trained to complete ISPs. will assure that the assessed care needs, from UAI, are appropriately addressed on the ISP. Over the next 30 days, until 8/1/2023, the ED/designee will complete a comparative review of new UAIs to ISPs to assure needs are appropriately addressed. [sic]
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to address all identified needs on Individualized Service Plans (ISPs). EVIDENCE: 1. Resident # 5 has an assistive device attached to her bed referred to by staff as a ?bed cane.? During interview with the LI, resident # 5 was able to explain what the device is used for. 2. Use of the bed cane is not included in the Individualized Service Plan (ISP) for resident # 5.
Plan of Correction:	Use of assistive device was added to resident #5 ISP. A review will be completed of current residents with assistive devices to ensure that those devices are accurately reflected in their ISP?s. Moving forward the Resident Care Director/designee will include appropriate assistive devices when completing the ISP. For the next 60 days, until 9/1/2023, the Executive Director/designee will complete a review of ISPs being completed to assure appropriate assistive devices are being included. [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on observations made during the medication cart audit, the facility failed to adhere to their medication management plan for proper disposal of medication. EVIDENCE: 1. During the medication cart audit on 06/07/2023, the LI observed Lantus Solostar insulin glargine injection 100 units/mL (U-100) 3mL Prefilled Pens for resident # 6 (open date 04/29/2023), resident # 7 (open date 05/02/2023) and resident # 8 (open date 05/03/2023). Per manufacturer instructions contained on the packaging, the medication must be used within 28 days after initial use. 2. During the medication cart audit on 06/07/2023, the LI observed a Humalog KwikPen insulin lispro injection for resident # 8 with an open date of 05/03/2023. Manufacturer instructions state the in-use Humalog KwikPen must be used within 28 days or be discarded, even if it still contains Humalog.
Plan of Correction:	For the next 60 days, until 9/1/2023, Medication carts will be audited by the ARCD/designee weekly to assure medications are being appropriately disposed of based on expiration date/date to be disposed per open date. The RCD/designee will audit each medication cart monthly to assure medications are being appropriately disposed of based on expiration date or/date to be disposed of based on open date. Plan moving forward is for the RCD/designee to complete monthly review of medication carts to assure proper disposal of medication. [sic]
Standard #:	22VAC40-73-680-D
Description:	Based on observations made during the morning medication pass and medication cart audit, the facility failed to ensure medications are administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlined in the current medication aide curriculum provided by the Virginia Board of Nursing. EVIDENCE: 1. Per physician?s orders as of 06/07/2023 and the Medication Administration Record (MAR) for June 2023, resident # 9 is prescribed GNP Nasal Moist 0.65% Spray, use 2 sprays in each nostril twice a day; this medication was not able to be located at the facility during the medication pass. 2. Per physician?s orders as of 06/07/2023 and the MAR for June 2023, resident # 10 is prescribed the following medications: D-Mannose 500mg Caps, take two capsules by mouth once daily; Mometasone Furoate 50mcg Spray, use 1 spray into each nostril once daily; Vitamin C 1000 Tabs, take one tablet by mouth once daily. These medications were not able to be located at the facility during the medication pass. 3. Per physician?s orders as of 06/07/2023 and the MAR for June 2023, Resident # 10 is prescribed Preservision Areds 2 Caps, take 1 capsule by mouth twice a day. There was an open date of 12/01/2022 on the packaging. According to the directions on the label and the contents in the container of 210 mini soft gels, the medication should have been depleted after approximately 3.5 months, which would have been by 03/15/2023. At the time of inspection on 06/07/2023, there were several soft gels/capsules remaining in the bottle.
Plan of Correction:	RCD/ designee to complete MAR to Cart audit by 7/15/2023. Medication staff will be provided training on reordering medications from family/outside pharmacy, and non-cycle fill medications by 7/15/2023 to assure continued compliance with regulatory standard. For the next 60 days, until 9/15/2023, the RCD/designee will complete a monthly audit of medication carts to assure medications are available per physician order. [sic]
Standard #:	22VAC40-73-680-E
Description:	Based on observations made during the morning medication pass, the facility failed to carry out treatments ordered by a physician or other prescriber according to prescriber?s instructions for one resident. EVIDENCE: 1. Resident # 10 is prescribed Diaper Goo/Greer?s Goo, cleanse right inner thigh & crease between legs and pelvis with mild soap and water, pat dry apply twice a day for 14 days. This medication was not able to be located at the facility during the medication pass.
Plan of Correction:	RCD/designee to complete MAR to Cart audit by 7/15/2023. Medication staff will be provided training on reordering medications from family/outside pharmacy, and non-cycle fill medications by 7/15/2023 to assure continued compliance with regulatory standard. For the next 60 days, until 9/15/2023, the RCD/designee will complete a monthly audit of medication carts to assure medications are available per physician order. [sic]
Standard #:	22VAC40-73-680-M
Description:	Based on observations made during the medication cart audit and interview with staff, the facility failed to ensure medications ordered for PRN administration are available and stored properly at the facility for one of the three resident records reviewed. EVIDENCE: 1. Per physician?s orders as of 06/07/2023 and the MAR for June 2023, resident # 10 is prescribed the following PRN medications: Diphenoxylate-Atropine 2.5, take two tablets by mouth every 8 hours as needed (start date 09/30/2022) and Ondansetron 4mg ODT Tablet, dissolve 1 tablet on tongue every 6 hours as needed (start date 07/18/2022). These medications were not able to be located at the facility during the onsite inspection.
Plan of Correction:	RCD/Designee will review current PRN orders and request discontinue of those medications not utilized in greater than 90 days, if appropriate. RCD/Designee to complete MAR to Cart audit by 7/15/2023. Medication staff will be provided training on reordering medications from family/outside pharmacy, and non-cycle fill medications by 7/15/2023 to assure continued compliance with regulatory standard. For the next 60 days, until 9/15/2023, the RCD/designee will complete a monthly audit of medication carts to assure medications are available per physician order. [sic]
Standard #:	22VAC40-73-750-B
Description:	Based on observations made during the tour of the building, the facility failed to ensure each resident room contained the required items. EVIDENCE: 1. There were no chairs observed by the LI in resident room #200 in the memory care unit. 2. Resident room #310 had two residents assigned to the room but only one chair available.
Plan of Correction:	Current resident apartments were audited to assure appropriate required items are available or there is documentation as to why, per resident request, item is not available. Moving forward, new move-ins will be made aware of what items are required to be in the room for the resident. If not available, the community will appropriately provide until resident/family is able to provide. [sic]
Standard #:	22VAC40-73-870-A
Description:	Based on a tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. In resident room #410, the carpet by the bed near the window had several dark stains on it and what appeared to be food crumbs scattered about. The trash can in front of the window near the same bed was full and overflowing with blue disposable under pads.
Plan of Correction:	Room 410 was deep cleaned, and carpet was shampooed. Housekeeping was re-educated on the importance of timely trash removal. A check of all rooms will be completed for cleanliness and any needed cleaning completed. [sic]