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 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/007/2023 Begin: 12:30am End: 12:50am The Acknowledgement of Inspection form was not signed and left at the facility for each date of the inspection; this inspection was conducted via email. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and staff interview the facility failed to administer medication in accordance with the physician?s instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Resident #1 is prescribed 0.25mg Xanax, take one tablet by mouth twice daily. 2. Staff #1 administered 0.25 mg Ativan to resident #1; instead of the prescribed 0.25 Xanax on 05/04/2
Plan of Correction:	1. At time of error, Resident #1 and her responsible party, physician, and pharmacy were made aware of the medication error. 2. Staff #1 was educated on the 5 rights of medication administration on 5/9/2023. Current RMA staff will be provided training to Completing Med Pass to include 6 rights of medication administration and controlled substance management by 7/31/2023. Ongoing training will occur at hire and as needed. 3. The RCD/designee will complete Med Pass Observation Competency with each current med tech by 8/31/2023 to assure understanding and competency of items reviewed during training. Moving forward Med Pass Observation Competency will be completed on new and current RMAs at hire and as needed. [sic]