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: Aug. 8, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/08/2023 Begin: 12:50pm End: 2:10pm 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: information not gathered 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: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: 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 staff interview, facility self-report, and resident record review, the facility failed to administer medications in accordance with physicians? instructions. EVIDENCE: 1. According to a self-report received by the Licensing Inspector on 07/21/2023 and 07/31/2023, and interviews with staff #1, #2, #3, and #4, on 08/08/2023 residents #1- #8 did not receive any of their prescribed medications during the facility?s scheduled 9pm medication pass. There were approximately 61 missed medications for residents #1-#8 according to the facility?s self-report. 2. During a telephone interview on 08/17/2023 and per a written statement from staff #1, she stated when she went into work at 10pm on 07/20/2023 she noticed several resident nighttime medications had not been documented as administered on the medication administration record (MAR). Staff # 1 stated she `signed them out?, clarifying that she initialed as if she administered the medications. Staff #1 stated she went through the MARs for residents #1- #8 and initialed the nighttime medications in which she thought had been administered by the off-going medication aide, staff #2 3. According to the facility?s self-report, resident #1 did not receive any of their 12 medications, resident #2 did not receive any of their six medications, resident #3 did not receive any of their seven medications, resident #4 did not receive any of their 13 medications, resident #5 did not receive any of their seven medications, resident #6 did not receive any of their three medications, resident #7 did not receive any of their eight mediations, and resident #8 did not receive any of their five medications at the evening medication pass on 07/0/2023. 4. According to an interview with staff #3 and #4, and a review of resident records, residents #1-#8 are all rated dependent in medication administration according to their Uniform Assessment Instruments (UAIs) and the facility administers all their medications as prescribed and according to the facility medication management plan.
Plan of Correction:	Staff 1 was relieved from med passes for 30 days pending completion of re-training including but not limited to 6 rights of medication administration and was observed during med pass by RCD. Current RMA?s were shadowed by RCD for a med pass. Med cart audits were completed weekly for four weeks. Staff 2 was scheduled for re-training but resigned before completion. Current RMA?s were observed during a med pass by RCD. Provider, responsible party, and home health or hospice were notified for those resident?s effected by incident. No changes in plan of care were recommended as a result of the omissions. No negative effects were noted. [sic]
Standard #:	22VAC40-73-680-E
Description:	Based on staff interview, the facility failed to provide medical procedures or treatments ordered by a physician according to his instructions. EVIDENCE: 1. Resident #1 has a physician?s order dated 06/27/2023 to record oxygen saturation twice daily, give oxygen at four liters for oxygen saturation below 90%, oxygen at four liters at night and as needed via nasal cannula by means of portable concentrator for oxygen saturation below 90% due to COPD. 2. Resident #2 has a physician?s order dated 05/30/2023 to check blood pressure and heart rate twice daily. 3. Resident #3 has a physician?s order dated 07/06/2023 to administer labetalol 100mg ? tablet by mouth at bedtime-hold for systolic blood pressure less than 120 or diastolic blood pressure less than 60 or pulse less than 60. 4. Resident #8 has a physician?s order dated 06/30/2023 to administer Nifedipine ER 30mg, one tablet by mouth at bedtime if systolic blood pressure is greater than 160. 5. Per a telephone interview with staff #1 on 08/17/2023, she stated to LI that she did not take resident #1?s oxygen saturation, resident #3 and #8?s blood pressure, and did not take resident #2?s blood pressure nor measure her pulse. 6. Staff #1 stated on 07/20/2023 she took a sticky note from the laptop on the medication cart where she relieved staff #2, the note had a list of oxygen saturations, blood pressures and pulses. Staff #1 stated to LI during a phone interview that she recorded the measurements onto the July 2023 MAR in order as they appeared on the note and documented them in corresponding order from smallest to greatest resident room numbers as if she herself had checked the above-mentioned vitals.
Plan of Correction:	Staff 1 was relieved from med passes for 30 days pending completion of re-training including but not limited to 6 rights of medication administration and was observed during med pass by RCD. Current RMA?s were shadowed by RCD for a med pass. Med cart audits were completed weekly for four weeks. Staff 2 was scheduled for re-training but resigned before completion. Current RMA?s were observed during a med pass by RCD. Provider, responsible party, and home health or hospice were notified for those residents effected. No changes in plan of care were recommended as a result of the omissions. No negative effects were noted. RCD re-educated current RMA?s on importance of obtaining and properly documenting vitals and following parameters [sic]