VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cardinal Senior Communities Roanoke
3585 Brambleton Ave
Roanoke, VA 24018
(540) 772-7181

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: Sept. 27, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/27/2023 from 09:00 AM until 11:00 AM 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: 18 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the initial inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The applicant has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to maintain future compliance with applicable standard(s) or law. If the applicant 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 should the facility be issued a license to operate. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. EVIDENCE: On the date of inspection, while performing a physical plant walk through, staff 1 and LI observed numerous ceiling stains and carpet stains throughout the facility which staff 1 identified as water damage stains.
Plan of Correction:	Areas identified with carpet stains will be cleaned, repaired and/or replaced in areas beyond repair. Areas identified with ceiling stains will be determined to be free of any active water leaks and repaired. The maintenance director will complete a full physical plant audit to ensure all areas impacted with water damage are identified and addressed appropriately. The maintenance director will monitor physical plant ongoing to address any further water related issues.
Standard #:	22VAC40-73-980-H
Description:	Based on observation and staff interview, the facility failed to ensure the availability of emergency food and drinking water. EVIDENCE: On the date of inspection, while performing a physical plant walk through, staff 1 and LI were unable to access the emergency food and drinking water supply behind a locked door with the keys and resources that were available in the facility.
Plan of Correction:	Emergency food and drinking water will be readily available and accessible. The administrator will ensure authorized facility staff have access to emergency food and water supply at all times. The administrator will complete monthly audits to ensure emergency supplies are accessible and in compliance with standards.