VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Virginia Veterans Care Center
4550 Shenandoah Ave.
Roanoke, VA 24017
(540) 982-2860

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

Inspection Date: Sept. 11, 2020

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 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Technical Assistance:

The LI and facility management discussed safe ways to complete fire drills during the coronavirus emergency. The facility will check with the local Fire Marshal if there are questions. There was a discussion regarding oxygen orders and capabilities of different types of equipment.

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 9/9/2020 and concluded on 9/11/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 23. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed three (3) resident records, three (3) staff records, staff schedules, fire drill records, background check review on new staff, health care oversight report, fire inspection report, and the health department report 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 #:	22VAC40-73-450-F
Description:	Based on resident record review and interview, the facility failed to address an assessed need on a resident's individualized service plan (ISP). EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 1 dated 1/6/2020 shows this resident has short term memory problems. The memory loss was confirmed with staff 5. This is not addressed on the ISP dated 2/12/2020.
Plan of Correction:	1. The ISP for Resident #1 was updated and corrections made. The corrected ISP was reviewed with the resident. 2. All ISP?s will be audited to verify that any short term memory loss listed on the UAI is correctly documented on the ISP. Audits will be conducted quarterly. 3. The ALF Unit Manager and/or designee will be responsible for the audits. Audit results will be reported to the quarterly Quality Improvement Committee meeting.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to have some required information on a medication administration record (MAR). EVIDENCE: 1. The MAR for resident 1 lack documentation to support that on 8/13/2020 the resident's blood sugar reading was taken before breakfast. hole in mar graham check bs
Plan of Correction:	1. Education of all ALF nurses regarding documentation of blood sugars on the Medication Administration Record and Treatment Administration Record. 2. Audits will be completed on MARs and TARs to verify all required documentation is completed. Audits will be conducted weekly for 4 weeks, every other week for 4 weeks, one time a month and then random. 3. The ALF Unit Manager and/or designee will be responsible for the audits. Audit results will be reported to the quarterly Quality Improvement Committee meeting.