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: March 6, 2024

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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 03/06/2024 from 09:15 AM until 02:45 PM and 03/07/2024 from 08:00 AM until 10:00 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-M
Description:	Based on record review, observation, and staff interview, the facility failed to ensure that medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility. EVIDENCE: 1. The record for resident 7 contained a signed medication list, dated 02/14/2024, which indicated a prescription for ACETAMINOPHEN 500 MG TAB ? TAKE 2 TABS = 1000 MG BY MOUTH EVERY 8 HOURS AS NEEDED FOR PAIN. 2. During the medication cart audit on the second day of the renewal inspection, LI and staff 2 was unable to locate this PRN ACETAMINOPHEN 500 MG medication on the cart, nor was it found in the nurse?s station. 3. An interview with staff 4 revealed that she was also unable to locate this PRN ACETAMINOPHEN 500 MG in the facility.
Plan of Correction:	Not available online. Contact Inspector for more information.