VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Cedar Manor
1324 Cedar Road
Chesapeake, VA 23222
(757) 548-4192

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Dec. 14, 2023

Complaint Related: Yes

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 22VAC40-80 COMPLAINT INVESTIGATION

Technical Assistance:

Personal and Social Information

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 12/14/2023 from 10:21 am to 2:38 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/27/23 and 11/28/23 regarding allegations in the area(s) of: Resident Care and Related Services, Building and Grounds, and The Safe Secure Environment Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation and review of the safe secure unit, round logs, staffing schedule, and the medication cart was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation?s area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-D
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP). Evidence: 1. The record for resident #2 contains the following: a hospice aide order dated 05/02/23-07/30/23; a hospice plan of care to include a start date of 05/02/23; hospice visit notes dated during the timeframe of 05/03/23 through 10/28/23. Resident?s #2 ISP dated 06/25/23 does not include the services provided by the hospice organization.
Plan of Correction:	What Has Been Done to Correct? Resident Files will be Audited for compliance. Any file found not compliant will address and correct at that time. How Will Recurrence Be Prevented? Resident Care Director/ Assistant Resident Care Director/ designee to appropriately update the ISP to include delineation of care tasks that the hospice provider may be providing. Executive Director will complete regular, random audits of those residents receiving hospice services to assure compliance. Person Responsible: Resident Care Director, Executive Director, or Designee
Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on the record review the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated, damaged, or contaminated medications. Evidence: 1. During the medication cart observation with staff #1 the following expired medication was observed on the medication cart located in the safe, secure unit: Senna Plus tablets, expired 09/07/23 for resident #1.
Plan of Correction:	What Has Been Done to Correct? Medication Carts will be Audited for compliance. Any items found not compliant will be address and corrected at that time. How Will Recurrence Be Prevented? RCD or Designee will conduct weekly audits on each medication cart to assure expired medications have been appropriately removed from the cart. Training will be provided to new and current RMAs will be trained on appropriately monitoring expiration dates. Training will be completed by 1/31/2024 Person Responsible: Resident Care Director, Executive Director, or Designee