VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Magnolia Ridge ALF
1007 Amherst Street, SW
Roanoke, VA 24015
(540) 342-8861

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: May 3, 2024

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: 05/03/2024 8:30am until 12:30pm 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: 24 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1040-A
Description:	Based on observations of the facility physical plant, the facility failed to ensure that a system of security monitoring was in place on doors leading to the outside for residents with serious cognitive impairments. EVIDENCE: 1. The alarms on the doors leading to the outside next to rooms 12 and 27 were not operable on the day of inspection. The facility houses a mixed population of residents such as resident 2 who has a diagnosis of Dementia, is assessed as non-ambulatory on a history and physical dated 03/21/2023 and is marked as disoriented to some spheres some of the time with time and place being the spheres affected on a uniform assessment instrument (UAI) dated 02/08/2024.
Plan of Correction:	Door alarms were purchased and will be install.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure that a statement that the individual does not have any prohibited conditions was included in the physical examination. EVIDENCE: 1. The record for resident 4, admitted on 03/22/2024, has documentation on the physical examination dated 03/20/2024 that resident 4 has the prohibited conditions, psychotropic medications without appropriate diagnosis and treatment plans and requires continuous licensed nursing care., making it unclear if this resident is appropriate for placement in an assisted living facility.
Plan of Correction:	The resident 4 placement in an assisted living facility is accurate. The documentation has been reviewed and corrected by the physician.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observations of the facility physical plant, the facility failed to ensure that all medications were stored in a locked area. EVIDENCE: 1. The storage closet next to room 18 was observed to be unlocked on the day of inspection and contained 2 boxes of Lidocaine 5% patches sitting out on a shelf in the closet.
Plan of Correction:	The staff were instructed to ensure the storage room always remain locked according to company policies and procedures. The 2 boxes of Lidocaine 5% patches were immediately removed.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to ensure that all required information was documented on resident medication administration records (MARs). EVIDENCE: 1. The April 2024 MAR for resident 3 has documentation of the PRN medication Lorazepam 0.25ml every 4 hours as needed for anxiety being administered on 04/07/2024 and 04/12/2024 and the PRN medication Morphine Sulf 0.25ml every 4 hours as needed for pain being administered on 04/06/2024 and 04/07/2024. The MAR does not have documentation of the effectiveness of these medications for the doses that were administered.
Plan of Correction:	The Medication Technicians have been instructed to continue to follow our medication plan and procedures for the documentation of administering PRNs.
Standard #:	22VAC40-73-690-B
Description:	Based on resident record review, the facility failed to ensure that a medication review was completed every 6 months for resident assessed as assisted living level of care. EVIDENCE: 1. The records for residents 2, 3 and 5 have documentation that the last review of medications for these residents was completed on 10/05/2023. All 3 of these residents are assessed as assisted living level of care on their uniform assessment instruments (UAI).
Plan of Correction:	Resident 2, 3, and 5 medication reviews have been received and placed in their charts. We will continue to work with our pharmacy to ensure timely compliance of our medication reviews.