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: Sept. 3, 2020 , Sept. 23, 2020 , Sept. 30, 2020 , Oct. 5, 2020 , Oct. 22, 2020 and Nov. 5, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 complaint investigation was initiated on 9/3/2020 and concluded on 11/5/2020. A complaint was received by the department regarding allegations in the areas of resident rights and resident care. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the monitoring inspection but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-310-A
Complaint related:	Yes
Description:	Based on interview and resident record review, the facility retained a resident they cannot provide care for. EVIDENCE: 1. The facility is unable to provide incontinence care for resident 1. The resident will not allow it. The uniform assessment instrument (UAI) dated 2/26/2020 shows resident 1 is incontinent of bladder weekly or more. The individualized service plan (ISP) dated 10/30/2019 shows that resident 1 wets the bed several times during the night and refuses staff assistance to change disposable brief and will not let staff change wet bedding. Interview with the administrator confirms that resident 1 will lay in a wet bad at night and that resident refuses needed care to remain clean and dry.
Plan of Correction:	Resident was re-educated on the care needed while living in community. Resident made aware on numerous occasions of possible discharge from community for not being compliant to care of allowing staff to meet her needs. Resident was discharge from community as of 11/1/20.
Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on resident record review, the facility failed to complete a uniform assessment instrument (UAI) in accordance with Assessment in Assisted Living Facilities (22VAC30-110). EVIDENCE: 1. The UAI for resident 2 dated 8/31/2020 shows this resident needs help with bathing, but the level of help needed is not indicated. 2. The UAI for resident 4 dated 11/13/2020 shows this resident needs both mechanical help only and human help with physical assistance for dressing and toileting. The same UAI is also lacking an assessment for behavior pattern. 3. The UAI for resident 3 dated 9/11/2020 shows this resident needs help with bathing, dressing, toileting, walking, stair-climbing, and mobility, but the level of help needed is not indicated.
Plan of Correction:	1. Resident #2 UAI has been corrected as resident does not need assistance with bathing. 2. Resident #4 UAI updated to reflect behavior patterns. 3. Resident #3 UAI corrected. Resident #3 Discharged 9/24/20 Administrator will audit charts weekly to ensure completion and any changes in care are updated.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on resident record review, the facility failed to address assessed needs on the comprehensive individualized service plan (ISP). EVIDENCE: 1. The uniform assessment instrument (UAI) dated 5/9/2020 for resident 5 shows this resident needs mechanical and human help with physical assistance with bathing. A note on the UAI states, "wash resident's back". The ISP dated 5/9/2020 states, "Resident will receive assistance with bathing. Grab bars are provided for use if needed at time of shower." The ISP does not address the nature of assistance to give the resident, and does not address washing the resident's back. The same UAI shows resident 5 needs mechanical help only with toileting, but the ISP states, "Resident requires no assistance during daytime ot toilet but does need assistance at night." The nature of the assistance to be given is not specified, and the mechanical assistance is not mentioned.
Plan of Correction:	Resident #5 UAI and ISP have been updated to reflect consistency on UAI and ISP. Administrator will audit charts weekly to ensure consistency is documented. Resident #5 UAI and ISP have been updated to reflect consistency on UAI and ISP. Administrator will audit charts weekly to ensure consistency is documented.
Standard #:	22VAC40-73-460-H
Complaint related:	Yes
Description:	Based on interview and resident record review, the facility failed to ensure that services for the needs of a resident were met. EVIDENCE: 1. Resident interviews reveal that residents who require assistance with incontinence, according to uniform assessment instrument (UAI), are not consistently assisted with being changed after being incontinent at night. One resident has identified staff 1 as stating the resident is only allowed to be changed once a night, and that if she needs it more often, she must wait until morning to be changed.
Plan of Correction:	Resident made aware that care is given 24 hours a day in community. Administrator and CEO interviewed Staff member #1 and was told that she never offered that information to any resident. Staff member #1 is a licensed CNA and is aware of proper protocol when providing care to residents.
Standard #:	22VAC40-73-550-C
Complaint related:	Yes
Description:	Based on interviews and resident record review, the facility failed to ensure that residents were accorded resident rights and responsibilities as provided in ? 63.2-1808-A-10 of the Code of Virginia. ? 63.2-1808-A-10 of the Code of Virginia states that the the resident has a right to have known needs not neglected or ignored by personnel of the facility. EVIDENCE: 1. A resident who has problems with incontinence as shown on the uniform assessment instrument (UAI) and has requested several times to be cleaned and changed during the night, and was told by staff 1 that the resident had to wait until the next shift came on duty, or that they were only allowed to change the resident one time only to save supplies. Interview with the administrator reveals that staff 1 was never instructed to only change residents once per night. The resident's UAI shows this person is incontinent of bowel and bladder weekly or more, and the individualized service plan (ISP) shows the resident will be assisted with cleaning and changing briefs when incidents of incontinence occurs. The ISP shows the service will be provided daily or as needed.
Plan of Correction:	Resident made aware that care is given 24 hours a day in community and made aware of resident rights to refuse. Administrator continue to train and retrain all staff on a consistent basis. Annual resident rights are reviewed and signed by staff and residents. Administrator will continue to have annual trainings with staff and residents on resident rights.