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. 26, 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: 09/26/2023 from 09:00 AM until 03:00 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 #:	22VAC40-73-210-D
Description:	Based on record review and staff interview, the facility failed to ensure that medication staff receive continuing education as required by the Virginia Board of Nursing. EVIDENCE: 1. The record for staff 1 did not contain evidence that staff 1 completed annual population-specific training in medication administration in the assisted living facility in which the aide is employed or an annual refresher course in medication administration, per section 18VAC90-60-100-B of the Virginia BON website continued competency for RMAs. 2. Interview with staff 4 also could not verify that staff 1 had received the annual medication administration training.
Plan of Correction:	1. Staff 1 completed her annual refresher course in medication administration on 10/02/2023. 2. All RMA's have been educated on the requirement to complete the annual refresher course and submit proof of training. 3. The Director of Education/Designee will verify that each RMA employed by the facility has completed the annual refresher course as required. A report will be given to the DON/Designee monthly. The issue will be discussed at the quarterly QAPI meeting until resolved.
Standard #:	22VAC40-73-325-B
Description:	Based on record review and staff interview, the facility failed to ensure that a fall risk rating is reviewed and updated after a fall. EVIDENCE: 1. The record for resident 4 contains an annual fall risk evaluation, dated 08/01/2023, which indicates that the resident has had no history of falls within the last six months; however, progress notes for resident 4, dated 06/18/2023, indicate that the resident self-reported to staff that she had fallen during the morning of 06/17/2023 and was transported to the hospital for treatment, but no corresponding fall risk evaluation was found in the record. 2. The record for resident 6 contains an annual fall risk evaluation, dated 08/10/2023, which indicates that the resident had 1 to 2 falls in the last six months; however, progress notes for resident 6 indicate that the resident had falls on 06/02, 06/03, 06/04, 07/16, 07/28, and 07/31/2023, but not all corresponding fall risk evaluations were found in the record. 3. Interview with staff 4 on the date of inspection revealed that staff were not aware that fall risk evaluations were required after a fall.
Plan of Correction:	1. A fall risk assessment for Resident 4 has been completed on 9/27/2023 to correspond with falls after the annual fall risk assessment was completed. 2. A fall risk assessment for Resident 6 has been completed on 9/27/2023 to correspond with falls after the annual fall risk was completed. 3. Education will be completed with all nursing personnel of the ALF that a fall risk evaluation will be completed after each fall incident sustained by the residents. 4. The Unit Manager/Designee will verify that a fall risk assessment has been completed following each incident and will report to the DON/Designee. !f a fall risk assessment has not been completed, the Unit Manager/Designee will re-educate the responsible staff member and verify that the assessment is completed. The issue will be discussed at the quarterly QAPI meeting until resolved.
Standard #:	22VAC40-73-640-A
Description:	Based on observation and staff interview, the facility failed to implement parts of its medication management plan, specifically regarding methods to ensure accurate counts of all controlled substances and infection control procedures related to blood glucose monitoring. EVIDENCE: 1. Page three of the facility?s medication management plan, last reviewed in June 2023, states that all controlled substances are verified by numerical count at the beginning and end of each shift by the current nurse and the oncoming nurse, including Registered Medication Aide. The facility?s narcotic count and card count form states the following: ?BY SIGNING THIS FORM, YOU ARE STATING THAT THE NARCOTIC COUNT AND CARD COUNT IS CORRECT PRIOR TO LEAVING AND ARRIVING?. 2. On the date of inspection, two Licensing Inspectors (LIs) and staff 1 observed that the September 2023 narcotic count and card count signature form for the ?DOM? unit did not contain signatures on the following dates and shifts: a. On 9/1/2023 by the 11 PM ? 7 AM leaving nurse. b. On 9/4/2023 by the 7 AM ? 3 PM arriving nurse and by the 3 PM ? 11 PM leaving nurse. c. On 9/5/2023 by the 7 AM ? 3 PM arriving nurse and 3 PM ? 11 PM leaving nurse shift. 3. Page two of the facility?s same medication management plan states that all glucometers and necessary components are to be labeled within specifically labeled containers for each individual resident?s use only. 4. On the date of inspection, two LIs and staff 1 observed that the glucometer unit for resident 6 was not labeled with the resident?s name.
Plan of Correction:	1. The narcotic count sheet has been corrected by the nursing staff who worked on those shifts. 2. The glucometer unit for resident 6 has been labeled with the residents name. 3. Education has been completed with all nursing staff on the medication management plan including the requirement to count narcotics and sign the narcotic count sheet by both the oncoming and outgoing nursing staff. All licensed nurses and RMA's have been educated on the labeling of glucometer units assigned to individual residents. An audit has been completed of all glucometer units and any necessary corrections made. 5. Audits will be conducted of narcotic count sheets by the Unit Manager/Designee 3 x week for 4 weeks, then 2 times a week for 4 weeks and then weekly for 4 weeks and prn. All audits will be turned in to the DON/Designee, 6. Audits will be conducted weekly of glucometer units assigned to individual residents weekly for 8 weeks and then prn. Audits will be turned in to the DON/Designee. These issues and audits will be discussed at the quarterly QAPI meeting until resolved.