VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Virginia's Assisted Living Facility
1205 Moorman Ave NW
Roanoke, VA 24017
(540) 343-3330

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

Inspection Date: Nov. 19, 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

Comments:

Three licensing inspectors conducted a one day unannounced mandated monitoring inspection at Virginia's Assisted Living Facility in Roanoke, Virginia on 11/19/2019. The inspection started at 10:15 am and concluded at 1:25 pm. The facility had 25 residents in care on the day of the inspection. The focus of this inspection was to monitor compliance with previous violations and compliance with standards following the current inspection protocol. A sample or resident and staff files were reviewed. The required postings were checked. The building was observed. The medication carts and medication administration records were reviewed. The noon medication pass was observed. Lunch and snacks were observed being served. Staff and resident interactions were observed. Background checks and sworn disclosures were reviewed for new hires. An exit meeting was held with the administrator and other key staff on 11/19/2019. At that time the opportunity was given to find items that were not readily available in files. As a result of this inspection, 12 violations are being cited. Please develop a plan of correction for each violation cited along with a date of correction and return a signed and dated copy back to the licensing office within 10 calendar days (12/05/2019) of receipt. If you have any questions please contact your inspector at 276-608-3514. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on review of resident records and disclosure forms, the facility failed to provide a statement to a prospective resident that discloses information about the facility. The statement shall be on a form developed by the department. EVIDENCE: 1. Resident #6 was admitted to the facility on 11/7/2019. The disclosure statement for this resident could not be located in the file. The facility could not produce the disclosed statement for this resident on the day of the inspection.
Plan of Correction:	The administrator will make sure all residents an or their legal representative receive a copy of the facility's disclosure statement. A copy of the disclosure statement initialed by the resident and or their legal representative will be kept in their file. 1. Resident #6's legal representative has received a copy of the facility's disclosure statement. She initialed the document and it has been placed in her file. [sic]
Standard #:	22VAC40-73-320-B
Description:	Based on review of staff records and health requirements, the facility failed to ensure one resident had a subsequent tuberculosis screening on an annual basis in a sample of six. EVIDENCE: 1. The most current tuberculosis screening located for resident #4 was dated 1/30/18.
Plan of Correction:	The administrator will make sure a risk assessment for tuberculosis is filed in the resident's record. [sic]
Standard #:	22VAC40-73-390-A
Description:	Based on review of resident records and written assurance documentation, the facility failed to ensure one resident in care received notification of written assurance in a sample of six. EVIDENCE: 1. Resident #6 was admitted to the facility on 11/7/19. There was documentation located in the resident's file to verify she had received written assurance the facility has the appropriate license to meet her care needs at the time of admission. This documentation could not be produced on the day of the inspection.
Plan of Correction:	The administrator will make sure all residents receive a copy of the facility's written assurance agreement. A copy of the agreement will be placed in their files at the time of admission along with documentation signed by the resident and or the resident's POA for verification. 1, Resident #6 has received and singed the facility's written assurance agreement. Documentation has been placed in her file. [sic]
Standard #:	22VAC40-73-440-C
Description:	Based on review of resident records and Uniform Assessment Instrument (UAIs), the facility failed to ensure one private pay UAI was completed for one resident in care. EVIDENCE: 1. Resident #5 was admitted tot he facility 04/10/2019. The licensing inspector could not locate the UAI for this resident in her file. According to Staff #5 she had completed the private pay UAI for this resident and was making updates to it this past week. The document could not be produced the day of the inspection. Staff # 5 stated she would not another private pay UAI for this resident.
Plan of Correction:	The administrator will make sure the completed the Uniform Assessment Instrument (UAI) is filed in the resident's record. 1. The UAI was located the same day the inspection was concluded and the document was placed in resident #5's file. [sic]
Standard #:	22VAC40-73-450-C
Description:	Based on review of staff records and Individual Service Plans (ISPs), the facility failed to ensure all identified needs were included on two resident's ISPs in a sample of six. EVIDENCE: 1. Resident #5 has a physician's order for a hospital bed that contains half rails as an assistive device. Resident #5 is aware of what the half rails are used for. Her ISP dated 11/13/19 did not include the half rails as an assistive device being an identified need. 2. Resident #6 was admitted to the facility on 11/7/2019. Her ISP was not located in her filed. According to staff #4 he was working on updating her ISP and did not save it properly and the document was lost. The ISP for resident #6 could not be produced on the day of the inspection.
Plan of Correction:	The administrator will make sure to include bed rails on all ISP's of residents who require bed rails. 1. Half bed rails have been added to resident #5's ISP. 2. The administrator will ensure a conscious effort to save documents while working on them. [sic]
Standard #:	22VAC40-73-450-E
Description:	Based on review of resident records and Individualized Service Plans (ISPs), the facility failed to ensure one resident singed their service plan in a sample of six. EVIDENCE: 1. Resident #5 was admitted to the facility on 4/10/19. Her ISP was updated on 11/13/19. The ISP was singed by the facility representative but not by the resident.
Plan of Correction:	The administrator will ensure all residents sign their individual service plans when there has been a revision or update. 1. Resident #5's ISP has been updated and placed in her file. [sic]
Standard #:	22VAC40-73-650-E
Description:	Based on review of resident records, the facility failed to chronologically file physician's orders in the resident records. EVIDENCE: 1. No physician's orders for Resident #10 wee filed chronologically in this file. 2. Two physician's orders were not filed chronologically for resident #9.
Plan of Correction:	The administrator an all certified medication aides will chronologically file physician's orders in the residents records. 1. NA 2. Staff #1 chronologically filed Resident #9's physician's orders. [sic]
Standard #:	22VAC40-73-660-A-1
Description:	Based on a tour of the building, the facility failed to store all medications in an area which was locked. EVIDENCE: 1. The laundry room was unlocked an in the room was an unlocked refrigerator which contained a vial of Amovig 70mg/ml and two containers of Latanoprost eye drops. 2. The first aid it in the unlocked laundry room and it contained a vial of antibacterial ointment.
Plan of Correction:	The administrator and all staff on duty will ensure the laundry room is kept locked and secured at all times. The administrator has met with all staff to ensure this standard is met. [sic]
Standard #:	22VAC40-73-680-D
Description:	Based on observations made during the review of the Medication Administration Record (MAR), and interviews with the staff the facility failed to administer all medications 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 #9's Ensure has not been available according to Staff #1 since this morning's medication pass at 8 am. His last dose was received yesterday at 5 pm. 2. Staff #1 signed off this morning for th e8 am dose as if she had administered the Ensure to him.
Plan of Correction:	The administrator has met with all appropriate staff members to make certain, that all certified medication aides and dietary staff will be sure that all residents with physician's orders receive dietary supplements such as Ensure, have them in the building at all times. Staff will not sign off on the MAR "given" for dietary supplements that have not been administered. **Resident #9 does not have a physician's order to receive Ensure. 1. Resident #8's Ensure was ordered and received by the facility the same day. 2. Staff #1 expressed that she understands she must follow proper protocol when signing the MAR. [sic]
Standard #:	22VAC40-73-680-I
Description:	Based on a tour of the building, the facility failed to store cleaning supplied in a locked area. EVIDENCE: 1. The laundry room was un-locked and in it housed an unlocked cabinet which container Pine Cleaner and Bleach.
Plan of Correction:	The administrator and staff on duty will ensure that cleaners and bleach will be kept secured at all times. The administrator has met with all staff to ensure this standard is met. [sic]
Standard #:	22VAC40-73-680-M
Description:	Based on observations made during the medication cart audits, the facility failed to maintain all as needed medications available to residents. EVIDENCE: 1. Resident #2 did not have her PRN (as needed) Acetaminophen 500mg and PRN Chloraseptic Spray available to her on the medication cart. 2. Resident #10 did not have his PRN throat lozenges available to him on the medication cart.
Plan of Correction:	The administrator and all certified medication aides will ensure residents prescribed PRN (as needed) medications will have them available in the medication cart at all times. 1. Staff #1 ordered Resident #2's PRNs and they arrived the same day. 2. NA Resident #9 PRN throat lozenge has not been taken since PRN order; there facility has contacted physician to d/c. [sic]
Standard #:	22VAC40-73-860-G
Description:	Based on observations made during the tour of the building, the facility failed to maintain hot water taps available to residents within a range of 105-120 degrees Fahrenheit. EVIDENCE: 1. The water temperature in both women's bathrooms had a water temperature of 130.8 degrees Fahrenheit in the sink.
Plan of Correction:	The administrator will ensure that the water temperature in the resident's bathrooms is within the range of 105-120 degrees Fahrenheit. All taps available to residents will be checked regularly by the administrator. [sic]