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 14, 2022

Complaint Related: No

Areas Reviewed:

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

860-G, 1110-A

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/14/2022 09:00 AM ? 04:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1070-B
Description:	Based on observation, the facility failed to ensure that when there are indications that ordinary materials or objects may be harmful to a resident with a serious cognitive impairment, these materials or objects shall be inaccessible to the resident except under staff supervision. EVIDENCE: 1. While completing a portion of the physical plant tour, between 9:30 AM and 10:00 AM, LI observed that the overhead cabinet in the bathroom of room 312 was unlocked and contained Dove deep moisture body wash, Tom?s of Maine deodorant, Neutrogena Healthy Scalp shampoo, and Gold Bond eczema relief cream. 2. While completing a portion of the physical plant tour, between 9:30 AM and 10:00 AM, LI observed that the overhead cabinet in the bathroom of room 313 was unlocked and contained hand sanitizer gel, DermaRite PeriGuard ointment, Degree deodorant, Freshscent roll-on deodorant, VO5 shampoo, Suave shampoo + conditioner, DermaRite moisturizing lotion, DermaRite perineal cleanser, and milk and honey hand wash. 3. While completing a portion of the physical plant tour, between 9:30 AM and 10:00 AM, LI observed an activity area which contained numerous activity supplies in various unlocked cabinets. One unlocked cabinet contained a plastic bin of various colors of nail polish and polish remover. Another unlocked cabinet contained an unlocked plastic bin of various craft paints, brushes, and buttons, and another open plastic bin of additional craft paints, pipe cleaners, and small decorative pom-poms.
Plan of Correction:	1. All identified materials and/or object that may be harmful to a resident with serious cognitive impairment were removed and immediately placed in a lockable/secure location. 2. Facility installed hidden protective locks on all accessible cabinets throughout unit to ensure cabinets automatically lock after use.
Standard #:	22VAC40-73-120-A
Description:	Based on record review, the facility failed to ensure that all staff shall receive the orientation and training as required in subsections of this regulation within the first seven working days of employment. EVIDENCE: 1. The record for staff 3, hired 03/30/2022, did not contain documentation that the staff member had received the required orientation and training within seven days of employment. 2. Interview with staff 4 and 5 indicated that staff 3 did not receive the specific orientation and training as required.
Plan of Correction:	1. Staff member 3 was oriented using facility form to document orientation. Orientation for staff member 3 was redone using DSS model form. 2. Facility implemented use of DSS model form for all new hire orientations.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive first aid certification within 60 days of employment. EVIDENCE: 1. The record for staff 3, hired 03/30/2022, did not contain any documentation that staff 3 has obtained first aid certification. 2. Interview with staff 4 and 5 indicated that staff 3 does not have current first aid certification.
Plan of Correction:	1. Staff member 3 received first aid certification. 2. Administrator or designee will audit all CNA and nurse employee files for First aid and CPR certifications 4 weeks post hire and annually to verify completion.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) contained all required components. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 1, dated 11/30/2021, indicated that the resident is disoriented to some spheres, all the time to time and place; however, the ISP for the resident indicated that the resident is disoriented to some spheres, all the time to time, place and situation. 2. Interview with staff 4 and 5 revealed that the UAI is correct and the ISP is incorrect. 3. The UAI for resident 5, dated 11/30/2021, indicated that the resident requires mechanical help and supervision human help with wheeling; however, the ISP for the resident, dated 12/07/2021, indicated that the resident is independent with wheeling. Also, the UAI for the resident indicated that the resident requires mechanical help and physical human assistance with mobility; however, the ISP for the resident indicated that the resident requires mechanical/supervision human assistance with mobility. 4. Interview with staff 4 and 5 revealed that the UAI is correct and the ISP is incorrect.
Plan of Correction:	Corrections were made to the ISPs for residents #1 and #5. Director of Nursing will complete random audits of the UAIs and ISPs monthly to ensure compliance and accuracy of all UAIs and ISP information.
Standard #:	22VAC40-73-640-A
Description:	Based on document review, the facility?s medication management plan did not contain all required components. EVIDENCE: The facility?s medication management plan provided during inspection, dated 12/07/2021, did not include methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Plan of Correction:	The Director of nursing will update the facility?s medication management plan to include all regulation requirements including the procedure to ensure accurate counts of all controlled substances.
Standard #:	22VAC40-73-860-D
Description:	Based on observation, the facility failed to ensure that any operable window (i.e., a window that may be opened) shall be effectively screened. EVIDENCE: While completing a portion of the physical plant tour, between 9:30 AM and 10:00 AM, LI observed that operable windows were not screened in any of the resident rooms.
Plan of Correction:	Facility installed screens on all operable windows within unit.