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: Oct. 1, 2021 , Oct. 6, 2021 and Oct. 8, 2021

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.

Comments:

A renewal inspection was initiated on 10/1/2021 and concluded on 10/8/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 17. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed two resident records, two staff records, activities calendar, menu, staff schedules, policies, fire and health inspections submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 10/8/2021. An exit interview was conducted with on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-270-3
Description:	Based on staff record review, the facility failed to have training on provided by a qualified health professional. EVIDENCE: 1. The training records for staff 1 and 2 show the training on methods of dealing with agitated or aggressive residents was provided by staff 6, who is not a qualified health professional. The record for staff 1 shows training was done on 9/28/2021 and the record for staff 2 shows the training was done on 7/17/2021.
Plan of Correction:	The Administrator who is also a qualified health professional shall provide training to staff as well as training materials when required during orientations. Records of each training`s hours will be kept on a roster in a binder going forward as well as in each employee file. Completion date 10/01/2021 and ongoing
Standard #:	22VAC40-73-290-A
Description:	Based on document review, the facility failed to maintain a written work schedule with an indication of whomever is in charge at any given time. EVIDENCE: 1. The work schedule dated 9/24/2021 through 10/8/2021 does not show who is in charge.
Plan of Correction:	Oversight was corrected at time of inspection. This Administrator has posted a work schedule indicating in their absence the Designated person in charge with an Asterisk (*) by the name, and a notation that indicates that the Asterisk designates the charge person on duty. Completion date 10/01/2021 and ongoing
Standard #:	22VAC40-73-620-A
Description:	Based on resident record review and document review, the facility failed to have an oversight at least every six months of special diets by a dietitian or nutritionist for each resident who has such a diet. EVIDENCE: 1. A physician's order sheet, signed on 9/2/2021, for resident 1 shows there is a special diet, "regular soft or bite sized if patient requests...") The resident roster sent at the start of the inspection showed resident 1 had a special diet of "Reg/Soft". The facility is not having dietitian or nutritionist oversights done every six months, as required for each resident who has a special diet.
Plan of Correction:	The Administrator has contacted a dietician and will have a dietitian oversight completed with those residents that are on a special diet. Completion date 10/28/2021 and ongoing
Standard #:	22VAC40-73-640-A
Description:	Based on document review, the facility failed to address some required sections of it's medication management plan. EVIDENCE: 1. The facilities medication management plan doe not address ordering medications in a timely manner and does not address periodic direct observation of staff during medication administration.
Plan of Correction:	The Administrator have implemented a plan with medication techs and Nurses that will notify the pharmacy of refills five days prior to the date they are expected to run out. This is address in the medication management plan. Going forward the Administrator will implement a sign-off sheet, recording dates of the he observation of medication techs and nurses administering medications. completion date 10/15/2021 and ongoing.
Standard #:	22VAC40-73-650-E
Description:	Based on resident record review and documentation review, the facility failed to have physician's or other prescriber's signed written orders in the residents records. EVIDENCE: 1. Resident 1 was administered the following medications since 10/1/2021 and orders were not signed and filed until 10/7/2021: Melatonin 3 mg (3 tablets for total of 9 mg); quetiapine fumarte 200 mg; cetiraxine 10 mg; eszopiclone 2 mg; invega sustenna 325 mg injection. The facility needed to get a copy from the pharmacy during the inspection.
Plan of Correction:	The Administrator shall ensure that all signed orders are copied and placed in the residents? charts prior to sending the pharmacy. A POS (physician order sheet) was signed in September 2021 that indicates medications orders for the above medication is good for one year. Per physician and pharmacy. The Administrator will continue to monitor this. Completed date 10/1/2021
Standard #:	22VAC40-73-660-A-7
Description:	Based on observation, the facility failed to have a piece of dedicated medical equipment labeled with the resident's name. EVIDENCE: 1. A glucometer for resident 3 did not have a name on the equipment.
Plan of Correction:	The administrator shall provide durable labels with the resident?s name on it to ensure that the resident name cannot be rubbed off during usage over time. Staff will have access to replacement label each time it becomes tattered. The administrator will monitor this frequently. Completion date 10/01/2021 and ongoing
Standard #:	22VAC40-90-40-B
Description:	Based on document review, the facility failed to obtain criminal history record reports on or prior to the 30th day of employment for each employee. EVIDENCE: 1. Staff 2 was employed on 7/15/2021. The staff record did not have the results from the criminal history record report as of 10/6/2021. 2. Staff 3 was employed on 8/10/2021. The staff record did not have the results from the criminal history record report as of 10/6/2021. 3. Staff 4 was employed on 8/9/2021. The staff record did not have the results from the criminal history record report as of 10/6/2021. 4. Staff 5 was employed on 7/13/2021. The staff record did not have the results from the criminal history record report as of 10/6/2021.
Plan of Correction:	This Administrator has requested and will correct the oversight of previous Management by ensuring background checks have been initiated on the first day of employment and not exceeding the 30th day of employment. Completion date 10/30/2021 and ongoing