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 17, 2020

Complaint Related: No

Areas Reviewed:

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 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

The licensing inspector, the facility administrator, and the unit manager had a discussion regarding MAR documentation.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 6/17/20 and concluded on 6/18/20. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 25. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, the Sworn Disclosure Statement and Criminal Record Report for all new staff members, resident roster, staff roster, staff schedule, facility health care oversight, fire and emergency drills, health department inspection, and dietitian oversight submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-320-A
Description:	320-A Based on record review, the facility failed to ensure that the physical examination and report contained any known allergies and a description of the person?s allergic reactions. EVIDENCE: The physical examination and report for resident 3, dated 1/17/2020, listed allergies to Penicillin, pollen, and Wellbutrin; however, the report failed to indicate a description of the resident?s allergic reactions to these medications.
Plan of Correction:	Plan of Correction: The history and physical examination for resident 3 was amended by the attending physician in order to reflect the resident?s allergies and their allergic reactions. All other history and physical examinations will be audited to verify they include any allergies and the description of the person?s allergic reaction. Any findings will be addressed accordingly. All new history and physical examinations will also be reviewed for completeness of the allergies and the person?s reaction. The clinical manager is responsible for compliance.
Standard #:	22VAC40-73-440-D
Description:	440-D Based on record review, the facility failed to ensure that the uniform assessment instrument (UAI) was completed as required. EVIDENCE: The UAI for resident 2, dated 4/13/2020, indicated that resident 2 needs help with continence of bowel and bladder; however, the type of help needed was not completed.
Plan of Correction:	Plan of Correction: The UAI for resident 2 was updated to include the type of help needed for bowel and bladder function. All other UAI?s will be audited to verify that the type of help is completed. Findings will be addressed accordingly. The clinical manager is responsible for compliance.
Standard #:	22VAC40-73-450-C
Description:	450-C Based on record review, the facility failed to ensure that the comprehensive individualized service plan (ISP) shall include a description of identified needs based upon the admission physical examination report. EVIDENCE: 1. The ISP for resident 3, dated 4/15/2020, did not include the need for oxygen therapy; however, the physical examination report indicated that two liters of oxygen therapy via nasal cannula are needed on a PRN basis. 2. The ISP for resident 1, dated 5/20/2020, did not include the resident?s allergy; however, the physical examination report indicated that the resident is allergic to Pravastatin. 3. The ISP for resident 1, dated 5/20/2020, indicated that the resident is on a regular diet; however, the physical examination report and staff interview indicated that the resident is on a regular diet with no added salt (NAS).
Plan of Correction:	Plan of Correction: The ISP for resident 3 was updated to reflect the need for oxygen therapy PRN. The ISP for resident 1 was updated to reflect the resident?s allergies and correct diet. All other ISP?s were audited for accuracy compared to the physical examination and any findings will be addressed accordingly. All ISP?s will be reviewed quarterly and compared with the current physical examination. The clinical manager is responsible for compliance.
Standard #:	22VAC40-73-460-D
Description:	460-D Based on record review and staff interviews, the facility failed to ensure the supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises. EVIDENCE: 1. The record for resident 3 indicated that the resident is cognitively impaired and has been diagnosed with dementia with behavioral disturbance and late onset Alzheimer?s disease. 2. The admission physical examination report for resident 3, dated 1/17/2020, indicated that due to her cognitive impairment, the resident should wear a wander guard at all times, in addition to having a bed alarm while in bed and a chair alarm while seated. 3. The uniform assessment instrument (UAI) for resident 3, dated 4/13/2020, indicated that the resident is disoriented to all spheres all of the time (date, time, and place). 4. The individualized service plan (ISP) for resident 3, dated 4/15/2020, indicated that the resident requires bed and chair alarms for safety to remind her to ask for assistance before transferring. 5. The ISP for resident 3, dated 4/15/2020, indicated that the resident needs assistance with bed mobility through the use of bilateral ? side rails with safety checks every two hours in order to promote independent bed mobility. 6. At the time of record review, the record for resident 3 did not contain documentation of physician?s recommendation of bilateral ? side rails. 7. When interviewed, staff 4 and staff 5 indicated that the resident knows how to use her bilateral ? side rails, and the resident knows what they are for. When asked to attempt to interview resident 3 by phone, staff 4 and staff 5 indicated that due to her significant cognitive impairment, the resident no longer understands how to use the telephone and would not be able to participate in a conversation. 8. Since the resident could not recognize how to use the phone, she was unable to verbalize to the inspector what the bed rails were for. As a result, the resident was unable to verify that she was functionally capable of safely using the rail.
Plan of Correction:	Plan of Correction The attending physician evaluated resident 3 and verified that although the resident is not able to have a phone conversation, she is able to use the side rails to sit up in bed when desired. All other residents using side rails will be assessed using the Side Rail Assessment and findings will be addressed accordingly. All residents use of side rails will be evaluated on admission and quarterly thereafter using the Side Rail Assessment form. All licensed nurses will be in-serviced on the use of the Side Rail Assessment form. The clinical manager is responsible for compliance.
Standard #:	22VAC40-73-680-H
Description:	680-H Based on record review, the facility failed to ensure that at the time 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: The current MAR for resident 2 did not contain any documentation for the scheduled 9 PM Flonase on 05/20/2020.
Plan of Correction:	Plan of Correction: The attending physician was notified of the med error for resident 2. No new orders noted. All other MARs will be reviewed for any holes or missing documentation and the findings will be addressed accordingly. All MARs will be audited weekly for completion and findings will be addressed directly with the nursing staff. All licensed nurses will be in-serviced on the medication management plan, including the accurate and complete completion of the MAR. The clinical manager is responsible for compliance.
Standard #:	22VAC40-73-710-C
Description:	710-C Based on record review, the facility failed to ensure that a restraint was imposed in accordance with a physician?s written order that specifies the condition, circumstances, and duration under which the restraint is to be used. EVIDENCE: 1. At the time of record review, the record for resident 3 did not contain a physician?s order for the use of bilateral ? side rails which were already being used on resident 3 who has a significant cognitive impairment.
Plan of Correction:	Plan of Correction: A physician?s order for the use of bilateral ? side rails for resident 3 was obtained. The attending physician evaluated resident 3 and verified that although the resident is not able to have a phone conversation, she is able to use the side rails to sit up in bed when desired and that she is not restrained by the use of the side rails. All other residents using side rails will be assessed using the Side Rail Assessment and findings will be addressed accordingly. All residents use of side rails will be evaluated on admission and quarterly thereafter using the Side Rail Assessment form. All licensed nurses will be in-serviced on the use of the Side Rail Assessment form and the facility?s restraint policy. The clinical manager is responsible for compliance.