VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brandon Oaks Intensive Assisted Living
3837 Brandon Avenue
Roanoke, VA 24018
(540) 562-5443

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: June 4, 2019

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 SANCTIONS.

Technical Assistance:

The facility received technical assistance on the following: 50 - discloses information about the facility shall be on a form developed by the department; 250C - all required personal and social data shall be maintained on staff; 290A - maintain a written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time; 310D - prior to admission of a resident, the assisted living facility administrator shall provide written assurance to the resident that the facility has the appropriate license to meet his care needs at the time of admission. Copies of the written assurance shall be given and a copy signed by the resident or his legal representative shall be kept in the resident's record; and 830E - facility shall provide a written response to the council prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns.

Comments:

The renewal inspection resulted in 13 violations. At 8:27 am, the inspection commenced and concluded at 6:09 pm. The census was 20 residents. During the inspection the following was reviewed: physical plant walk through; 6 residents and 4 staff records review; medication pass observation; interviews and other reviews. After completing the inspection, the facility staff and LI discussed the violations, possible corrective actions and had an open discussion. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain the following: 1) steps to correct the noncompliance with the standard(s); 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Please contact your license inspector, if you have any further concerns 540 309 5982.

Violations:

Standard #:	22VAC40-73-220-A
Description:	Based on staff interview and resident record review, the facility failed to ensure private duty personnel services were referenced on resident individualized service plans (ISP). Evidence: 1. Resident 4 has a private duty attendant. The facility did not document the services provided by the private duty personnel on resident 4's ISP. Staff 2 confirmed the facility was not in compliance with this standard.
Plan of Correction:	Resident 4?s ISP was updated to reflect the services provided by the private duty personnel on June 4, 2019. The ISP for other residents with private duty personnel were audited for compliance. The Clinical Manager will ensure that all ISP?s for residents with private duty personnel reflect the services they receive.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review and staff interview, the facility failed to ensure the physical examination report included all the required information. Evidence: 1. Resident 6's 5/15/19 physical examination report did not include: a) address b) phone number and c) reaction to amoxicillin allergy.
Plan of Correction:	The physical examination report for Resident 6 was amended to reflect the resident?s address, phone number and reaction to amoxicillin allergy. All other physical examination reports were audited for compliance. The Clinical Manager will ensure that all new physical examination reports are completed with all the required information.
Standard #:	22VAC40-73-390-A
Description:	Based on resident record review and staff interview, the facility failed to ensure the written agreement/acknowledgment included all the required information. Evidence: 1. Residents 6, 7 & 11 were missing the following from their resident/agreement contract: a) The resident has been informed of the policy required by 22 VAC 40-73-840 regarding pets living in the facility; b) The resident has been informed and had explained to him that he may refuse release of information regarding his personal affairs and records to any individual outside the facility, except as otherwise provided in law and except in case of his transfer to another caregiving facility, notwithstanding any requirements of this chapter; c) The resident has been informed of the rules and restrictions regarding smoking on the premises of the facility, including that which is required by 22 VAC 40-73-820; d) The resident has been informed of the policy regarding the administration and storage of medications and dietary supplements; e) The resident has been notified in writing whether or not the facility maintains liability insurance that provides at least the minimum amount of coverage established by the board for disclosure purposes set forth in 22 VAC 40-73-45 to compensate residents or other individuals for injuries and losses from negligent acts of the facility. The facility shall state in the notification the minimum amount of coverage established by the board in 22 VAC 40-73-45. The written notification must be on a form developed by the department; and f) The resident has received written assurance that the facility has the appropriate license to meet his care needs at the time of admission, as required by 22 VAC 40-73-310 D.
Plan of Correction:	All new admissions, or their respective representatives, from the time of this inspection and thereafter, will receive a resident admission agreement containing all the information outlined in 22VAC40-73-(5)-390-A. All other residents, or their respective representatives, who do not have a complete agreement, will be sent a letter with the remaining information. The Administrator is responsible for compliance and will audit new resident admission agreement.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review and staff interview, the facility failed to ensure the uniform assessment instrument (UAI) is completed as required by 22VAC30-110. Evidence: 1. Resident 6 requires physical assistance and handrails for stair climbing. Staff 2 confirmed the UAI was completed incorrectly. The UAI should not be assessed as is not performed. 2. Resident 7 requires physical assistance and handrails for stair climbing. Staff 2 confirmed the UAI was completed incorrectly. The UAI should not be assessed as is not performed. 3. Resident 11 requires physical assistance and handrails for stair climbing. Staff 2 confirmed the UAI was completed incorrectly. The UAI should not be assessed as is not performed.
Plan of Correction:	The UAI for Residents 6, 7 and 11 have been corrected, to reflect that the resident would require assistance for stair climbing. All other UAI?s were audited for compliance. The Clinical Manager and the Administrator are responsible for accurate completion of the UAI?s and will monitor semi-annually and with any significant changes.
Standard #:	22VAC40-73-450-C
Description:	Based on residents' record review and staff interview, the facility failed to ensure individualized service plan (ISPs) included all the required information. Evidence: 1. Resident 11 has a physician's order for a mechanical soft diet. This was not listed on the ISP.
Plan of Correction:	After an evaluation by the facility?s speech language pathologist, the order for mechanical soft was discontinued for Resident 11. All other ISP?s were audited for compliance on diet orders. The Clinical Manager will ensure that ISP?s will reflect the resident?s current diet orders.
Standard #:	22VAC40-73-640-A
Description:	Based on resident medication cart audit and staff interview, the facility failed to successfully implement their medication management plan: Evidence: 1. The control substance shift change count sheet was not completed correctly. On 4/18/19, 5/3/19, 5/8/19, 5/29/19 and 6/3/19, at least one shift did not have both on going and off going staff signatures. On 6/4/19, the morning and evening shift section was completed by the day shift employee hours before shift change occurred. 2. Resident 1 is prescribed cephalexin. On 4/10/19, the medication was not given as the drug was not available. Resident 1 is prescribed risperidone. On 5/24/19, the medication was discontinued. On 6/4/19, the medication remained in the cart. Resident 1 is prescribed levothyroxine in the morning. On 5/25/19, the day shift employee marked the medication as given on the previous shift, the night shift. 3. Resident 2 is prescribed levothyroxine in the morning. On 5/25/19, the day shift employee marked the medication as given on the previous shift, the night shift. Resident 2 is prescribed acetaminophen 3 times a day. On 5/25/19, the day shift employee marked the medication as given on the previous shift, the night shift. 4. Resident 3 is prescribed omeprazole in the morning before breakfast. On 5/25/19, the day shift employee marked the medication as given on the previous shift, the night shift. Resident 3 is prescribed no sting skin prep at night. On 5/31/19, the day shift employee marked the medication as given on the previous shift, the night shift. 5. Resident 4 is prescribed omeprazole in the morning. On 5/25/19, the day shift employee marked the medication as given on the previous shift, the night shift.
Plan of Correction:	1. The control substance shift change count sheet will be reformatted to improve ease of use and monitoring. 2-5. Residents 1, 2, 3 & 4?s attending physicians were notified of the administration variance, with no new orders except Resident 1?s order for risperidone was discontinued. All other MARs have been audited for compliance. Licensed nurses will be in-serviced on the facility?s Medication Management Plan and proper MAR documentation. The Clinical Manager is responsible for compliance and will monitor weekly.
Standard #:	22VAC40-73-680-C
Description:	Based on MAR review and staff interview, the facility failed to ensure medications were not administered earlier than one hour before and not later than one hour after the facility's standard dosing schedule. Evidence: 1. Resident 1 is prescribed latanoprost daily in the evening. The schedule dosing schedule is 9 pm. On 4/1/19, staff 2 administered the medication at 5:0 7 pm at the resident's request. Resident 1 is prescribed timolol malete. The standard dosing schedule is 8 pm. Staff 2 administered the medication at 5:07 pm. On 4/1/19, staff 2 acknowledged the administration is in violation of this standard. 2. Resident 4 is prescribed acetaminophen 3 times a day. On 4/26/19, the facility administered the medication at 12:13 pm, despite the standard dosing indicating 2 pm.
Plan of Correction:	Resident 1 and Resident 4?s physician was notified of the administration variance with no new orders noted. All other MARs have been audited for compliance. Licensed nurses will be in-serviced on the facility?s Medication Management Plan and proper MAR documentation. The Clinical Manager is responsible for compliance and will monitor weekly.
Standard #:	22VAC40-73-680-D
Description:	Based on MAR review and staff interview, the facility failed to ensure all medications were administered in accordance with the physician's or other prescriber'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 florastor at bedtime. The 4/8/19 MAR denotes it was not administered "due to condition". Staff 2 confirmed the medication was not administered as ordered. Resident 1 is prescribed risperidone. On 4/25/19, the medication was not administered. The MAR notes says "PRN , not needed". This medication was not PRN.
Plan of Correction:	Resident 1?s attending physician was notified of the administration variance. Resident 1?s order for risperidone was discontinued. All other MARs have been audited for compliance. Licensed nurses will be in-serviced on the facility?s Medication Management Plan and proper MAR documentation. The Clinical Manager is responsible for compliance and will monitor weekly.
Standard #:	22VAC40-73-680-H
Description:	Based on MAR review and staff interview, the facility failed to ensure at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements. Evidence: 1. Resident 1's MAR denoted medication administration was not documented at the time of admission no less than 45 times in April 2019 and no less than 41 times in May 2019. 2. Resident 2's MAR denoted medication administration was not documented at the time of admission no less than 7 times in April 2019 and no less than 6 times in May 2019. 3. Resident 3's MAR denotes medication administration was not documented at the time of admission no less than 11 times in April 2019 and no less than 9 times in May 2019. 4. Resident 4's MAR denotes medication administration was not documented at the time of admission no less than 4 times in April 2019 and no less than 11 times in May 2019.
Plan of Correction:	A new communication sheet was adopted for nurses to complete at the end of the shift, verifying that the medications due that shift were given or accounted for in the Electric Health Record (EHR). All other MARs have been audited for compliance. Licensed nurses will be in-serviced on the facility?s Medication Management Plan and proper MAR documentation. The Clinical Manager is responsible for compliance and will monitor weekly.
Standard #:	22VAC40-73-680-M
Description:	Based on staff interview and medication cart review, the facility failed to ensure medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility. Evidence: 1. Resident 1 is prescribed robafen PRN. The medication was not available.
Plan of Correction:	The prescribed robafen for Resident 1 was discontinued, as the resident no longer requires this PRN medication. The medication cart was audited to make sure all prescribed medication for all residents, including PRN medications, are in the cart or in the station?s medication room. The Clinical Manager is responsible for compliance and will monitor for compliance weekly.
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review and staff interview, the facility failed to ensure the valid physician's or other prescriber's oxygen order included all the required components. Evidence: 1. Resident 11 uses oxygen. The physician's order does not indicate the oxygen source nor delivery device.
Plan of Correction:	The order for supplemental oxygen for Resident 11 was discontinued on June 4, 2019, as the resident no longer needs it. All other oxygen orders were audited for compliance. The Clinical Manager will in-service all licensed nurses on writing orders for supplemental oxygen and will monitor for compliance.
Standard #:	22VAC40-73-950-C
Description:	Based on staff interview, the facility failed to implement an orientation and semi-annual review on the emergency preparedness and response plan for all residents, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating. Evidence: 1. Staff 1 confirmed the last emergency preparedness and response plan review for residents was one year ago. The 6 months review was not completed for residents.
Plan of Correction:	The Clinical Manager or Administrator will review the facility?s emergency preparedness and response plan with all residents or their respective representatives. The Administrator is responsible for ensuring compliance of this requirement semi-annually thereafter.
Standard #:	22VAC40-73-980-B
Description:	Based on physical plant observation, the facility failed to have a complete first aid kit in the motor vehicle used to transport residents. Evidence: 1. Staff 1 confirmed the flashlight in the van #6 was inoperable. The extra batteries in the first aid kit were the wrong size.
Plan of Correction:	The inoperable flashlight in the first aid kit was replaced with a working flashlight and the appropriate size batteries. The head of the transportation department will check the flashlights in the transportation vans monthly. The administrator will audit for compliance every other month.