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: May 22, 2023

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 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 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 05/22/2023 from 08:45 AM until 02:45 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 #:	22VAC40-73-1090-A
Description:	Based on resident record review, the facility failed to ensure that prior to admission to a safe, secure environment, all residents were assessed as having a serious cognitive impairment (SCI) due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. EVIDENCE: 1. Resident 1 was admitted to the facility on 04/17/2023 and the undated assessment of serious cognitive impairment form (ASCI) for resident 1 indicated that resident 1 can recognize danger or protect his or her own safety and welfare. 2. Resident 4 was admitted to the facility on 12/23/2022 and the ASCI for resident 4, dated 12/21/2022, indicated that resident 4 can recognize danger or protect his or her own safety and welfare.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-1100-A
Description:	Based on resident record review and staff interview, the facility failed to obtain written approval of one the required persons prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment. EVIDENCE: 1. The census report provided during on-site inspection on 05/22/2023 by staff 4 and the record for resident 1 contains documentation that the resident was admitted to the facility on 04/17/2023. 2. The approval for placement in a special care unit document was not signed by the resident?s spouse until 04/27/2023 giving approval for the resident to be placed in a safe, secure environment. 3. Interview with staff 4 confirmed that the aforementioned information is accurate.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-190-C
Description:	Based on record review, the facility failed to ensure that prior to being placed in charge, the staff member shall be informed of and receive training on his duties and responsibilities and provided written documentation of such duties and responsibilities. EVIDENCE: 1. The record for staff 1, hired 06/30/2020, did not contain evidence that staff 1 had been informed of duties and responsibilities and provided written documentation of such duties. 2. Interview with staff 4 and 5 indicated that there are shifts where staff 1 could be in charge.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-250-C
Description:	Based on record review, the facility failed to ensure that certain personal and social data is to be maintained on staff and included in the staff record. EVIDENCE: The record for staff 1, hired 06/30/2020, did not contain verification that the staff person has received a copy of his current job description.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-270-1
Description:	Based on record review and staff interview, the facility failed to ensure that for staff in assisted living facilities that accept, or have in care, residents who are or who may be aggressive or restrained, that direct care staff shall be trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents; This training shall include, at a minimum, information, demonstration, and practical experience in self-protection and in the prevention and de-escalation of aggressive behavior. EVIDENCE: 1. The record for staff 1, hired 06/30/2020, did not contain documentation or evidence of an annual refresher training in aggressive behaviors. 2. The record for staff 3, hired 04/05/2023, did not contain documentation or evidence that the staff member had received aggressive behavior training prior to being involved in the care of such residents. LI observed staff 3 on-duty during the on-site inspection. 3. The record for staff 2, hired 02/27/2023, did not contain documentation or evidence that staff 2 has had training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. 4. Interview with staff 4 revealed that the most recent aggressive behavior training that was scheduled in March 2023 had been canceled by the provider and the facility has been unable to find another provider since that time as of the date of inspection on 05/22/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-310-D
Description:	Based on resident record review and staff interview, the facility failed to ensure, based upon review of the uniform assessment instrument (UAI), that the administrator provided written assurance to a resident that the facility has the appropriate license to meet his care needs at the time of admission. EVIDENCE: 1. The census report provided during on-site inspection on 05/22/2023 by staff 4 and the record for resident 1 contains documentation that the resident was admitted to the facility on 04/17/2023. 2. The record for resident 1 contains documentation that written assurance was not provided to the resident and/or the resident?s legal representative until 04/27/2023. 3. Interview with staff 4 confirmed that the aforementioned information is accurate.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to ensure that prior to or at the time of admission to an assisted living facility that all required personal and social information on a person was obtained. EVIDENCE: The resident ? personal/social data document for resident 1 did not include information regarding the resident?s current behavioral and social functioning regarding strengths and problems on page 2 of 2.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review, the facility failed to ensure that a uniform assessment instrument (UAI) was completed as required. EVIDENCE: The UAI for resident 1, dated 04/14/2023, did not contain the signature of the administrator or designee on page 2. This was also noted by staff 4.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure that an individualized service plan (ISP) for a resident contained all required components. EVIDENCE: 1. The ISP for resident 3, dated 11/30/2022, indicates that the resident has someone with them during waking hours and that individual can assist with eating, toileting, and advocating for the resident. 2. Interview with staff 4 revealed that the resident does have private duty aides, whenever they are available from collateral 2; however, the private duty individual(s) from collateral 2 are not listed on the resident?s ISP as a companion services provider to resident 3.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-550-G
Description:	Based on record review, the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual. EVIDENCE: 1. The record for resident 2, admitted 12/09/2021, did not contain documentation of an annual review of resident rights since admission. 2. The record for resident 3 contained documentation that the most recent resident rights review was conducted with the resident and/or the resident?s legal representative on 04/10/2020 and with resident 5 and/or the resident?s legal representative on 02/02/2021. 3. Interview with staff 4 confirmed that this is accurate.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-640-A
Description:	Based on observation during medication cart audit and policy review, the facility failed to ensure that it implemented a portion of its medication management plan. EVIDENCE: 1. The facility?s medication management plan, with an effective date of June 2022, indicates that controlled drugs will be counted each shift by nursing staff coming on with the nursing staff going off to ensure accurate counts of all controlled medications. 2. During the audit of the facility?s medication cart, it was noted by two licensing inspectors (LIs) that from 05/01/2023 until the date of inspection on 05/22/2023, there was no documentation to indicate that staff coming on duty for their shifts have been counting with off-going staff every shift.
Plan of Correction:	Not available online. Contact Inspector for more information.