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: Nov. 14, 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 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:

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: 11/14/2023 8:30AM until 3:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 18 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: medication administration, medication cart audit, and noon-time meal An exit meeting will be conducted to review the inspection findings. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on staff record review and staff interview, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents shall submit the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the Virginia Department of Health or a form consistent with it. EVIDENCE: During on-site inspection on 11/14/2023, the records for staff person 1, date of hire 11/02/2023 and first day of work 11/04/2023, and staff person 3, first day of work 10/31/2023, did not contain the results of a risk assessment documenting the absence of TB. Interview with staff person 4 confirmed that this was accurate.
Plan of Correction:	Corrected: Going forward the Administrator will ensure dates are in compliance
Standard #:	22VAC40-73-320-B
Description:	Based on resident record review and staff interview, the facility failed to ensure that a risk for tuberculosis (TB) shall be completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. EVIDENCE: Resident 4 was admitted to the facility on 05/24/2021. During on-site inspection on 11/14/2023, the most recent TB screening form in the record for resident 4 was dated 04/14/2022. Interview with staff person 4 confirmed that this was accurate.
Plan of Correction:	Corrected: Going forward the Administrator will ensure dates are in compliance
Standard #:	22VAC40-73-350-B
Description:	Based on resident record review, the facility failed to ensure prior to admission whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall document in the resident?s record that this was ascertained and the date the information was obtained. EVIDENCE: Resident 2 was admitted to the facility on 04/18/2023. During on-site inspection on 11/14/2023, the record for resident 2 did not contain documentation on whether or not the resident is a registered sex offender.
Plan of Correction:	Corrected: Going forward the Administrator will ensure the sex offender verification gets placed in file at time of admission.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission. EVIDENCE: Resident 3 was admitted to the facility on 06/08/2023. During on-site inspection on 11/14/2023, interview with staff person 4 revealed that the comprehensive ISP for resident 3 has not been completed.
Plan of Correction:	Corrected: The Administrator will ensure that comprehensive ISPs are completed and placed in file within the correct time frame.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and staff interview, the facility failed to ensure that individualized service plans (ISPs) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. EVIDENCE: 1. During on-site inspection on 11/14/2023, the ISP in the record for resident 4 was dated 05/23/2022 and the ISP in the record for resident 5 was dated 03/22/2022. During an interview with two licensing inspectors (LIs) and staff person 4, staff person 4 revealed that these were the most recent ISPs for residents 4 and 5 and that an updated ISP has not been completed for residents 4 and 5.
Plan of Correction:	Corrected: The Administrator will develop a plan to ensure the updated ISP?s get completed annually and file prior to expiration dates
Standard #:	22VAC40-73-550-G
Description:	Based on resident record review and staff interview, the facility failed to ensure 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. During on-site inspection on 11/14/2023, the record for resident 4 contained documentation that the most recent review of residents? rights and responsibilities was conducted with resident 4 on 07/15/2022. The record for resident 5, admitted to the facility on 03/22/2022, did not contain documentation of the resident having a review of residents? rights and responsibilities. 2. Interview with staff person 4 confirmed that the aforementioned information is accurate.
Plan of Correction:	Corrected: The Administrator will develop a check off sheet to ensure resident rights form get completed annually and file in charts prior to expiration date
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to ensure that the medication administration record (MAR) shall include the date and time given and initials of direct care staff administering the medication. EVIDENCE: 1. The November 2023 MAR for resident 6 indicates that the resident is prescribed Clozaril 100MG half tablet in the morning, one and a half tablets at 4:00PM and four tablets at 9:00PM every day for psychosis. 2. The November 2023 MAR for resident 6 does not include the date, time given and initials of the staff person who administered the aforementioned medication at 4:00PM on 11/11/2023 and 11/13/2023 and at 8:00AM on 11/13/2023 to the resident.
Plan of Correction:	Corrected: The Administrator met with all licensed med-techs to go over policy on correct documentation for Medication record.
Standard #:	22VAC40-73-690-B
Description:	Based on resident record review, the facility failed to ensure for each resident assessed for assisted living care, except for those who self-administer all of their medications, a licensed health care professional, practicing within the scope of his profession, shall perform a review every six months of all the medications of the resident. EVIDENCE: 1. Resident 2 was admitted to the facility on 04/18/2023. 2. The uniform assessment instrument (UAI) for resident 2, dated 04/17/2023, indicates that the resident is assisted living level of care and does not self-administer their medications. 3. During on-site inspection on 11/14/2023, the record for resident 2 did not contain a review of all of the resident?s medications by a licensed health care professional.
Plan of Correction:	Corrected: The Licensee met with current pharmacy to request six month review records (Review was completed in August 2023) Going for the Administrator will ensure these are sent and filed within correct time frame.
Standard #:	22VAC40-90-30-B
Description:	Based on staff record review, the facility failed to ensure that a sworn statement or affirmation shall be completed for all applicants for employment. EVIDENCE: 1. The record for staff person 1 noted that their date of hire was 11/02/2023 and their first day of work was 11/04/2023; however, the sworn statement or affirmation for adult facility employees was not signed by staff person 1 until 11/06/2023. 2. The record for staff person 3 noted that their first day of work was 10/31/2023; however, the sworn statement or affirmation for adult facility employees was not signed by staff person 3 until 11/05/2023. 3. The record for staff person 5 noted that their date of hire was 11/03/2023; however, the sworn statement or affirmation for adult facility employees was not signed by staff person 5 until 11/10/2023.
Plan of Correction:	Corrected: Going forward the Administrator will ensure dates are in compliance