VIRGINIA DEPARTMENT OF SOCIAL SERVICES

North Roanoke Assisted Living
6910 Williamson Road
Roanoke, VA 24019
(540) 265-2173

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: July 17, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 63.2 Protection of adults and reporting.

Comments:

On 7/17/2019 one inspector conducted a complaint investigation (10:05am to 12:05pm) with a worker from another agency. The complaint alleged that a staff person used profanity directed toward a resident. Two staff people were interviewed, and a partial review of the residents chart was done. Staff interviews reveal that the resident was intoxicated and verbally abusive toward the staff member, who then reacted by directing profanity toward the resident. Based on available evidence, this complaint is valid/founded. The administrator, LI, and worker from the other agency discussed getting physician input about the resident using a medication to help with alcohol abuse. There was also discussion of enforcing that staff always report every incident to the administrator and to document them in the resident record.

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on document review, the facility failed to report an incident to the licensing office. EVIDENCE: 1. An incident occurred on 7/9/2019 involving suspected verbal abuse of resident 1 by staff 1. When the administrator was notified of the incident by staff 1, it was not reported to licensing.
Plan of Correction:	North Roanoke Assisted Living will comply with the Standard 22 VAC 40-73-(2)-70-A. NRAL will report to the Piedmont Licensing office any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. The facility will directly address any incident that impacts the residents in their care with immediate responses from Administration/Management. NRAL will continue to provide ongoing training for all employees as it relates to Resident Rights and Mandated Reporting. This plan of correction is submitted as required under State and Federal law. The submission of this Plan of Correction does not constitute an admission on the part of North Roanoke Assisted Living as to the accuracy of the surveyor?s findings or the conclusions drawn therefrom. Submission of this Plan of Correction also does not constitute an admission that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the North Roanoke Assisted Living?s policies and procedures should be considered subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence and any corresponding state rules of civil procedure and should be inadmissible in any proceeding on that basis. North Roanoke Assisted Living submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against North Roanoke Assisted Living or any employee, agent, officer, director, attorney, or shareholder of North Roanoke Assisted Living.
Standard #:	22VAC40-73-550-C
Complaint related:	Yes
Description:	Based on interview, the facility failed to ensure that resident rights were implemented. EVIDENCE: 1. ? 63.2-1808-A-11 states that residents are to be treated with courtesy, respect, and consideration as a person of worth, sensitivity, and dignity. An interview with staff 1 reveals that she used profane language toward resident 1 on 7/9/2019. The administrator stated that this was reported to him.
Plan of Correction:	North Roanoke Assisted Living will comply with the Standard 22VAC40-73-(6)-550-C. NRAL is required to have all employees read and understand the Resident Rights upon hire which is acknowledged with their signature. NRAL employees also review the resident rights annually. NRAL has conducted additional trainings with the identified employee which included human rights and confidentially and boundaries. The identified employee was also informed about the mandated reporting. NRAL will continue to provide ongoing training for all employees as it relates to Resident Rights. This plan of correction is submitted as required under State and Federal law. The submission of this Plan of Correction does not constitute an admission on the part of North Roanoke Assisted Living as to the accuracy of the surveyor?s findings or the conclusions drawn therefrom. Submission of this Plan of Correction also does not constitute an admission that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the North Roanoke Assisted Living?s policies and procedures should be considered subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence and any corresponding state rules of civil procedure and should be inadmissible in any proceeding on that basis. North Roanoke Assisted Living submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against North Roanoke Assisted Living or any employee, agent, officer, director, attorney, or shareholder of North Roanoke Assisted Living.
Standard #:	63.2-1606-BA
Complaint related:	No
Description:	Based on interviews, the facility failed to ensure that an incident of suspected abuse was reported to the local social services or to the adult protective services (APS) hotline. EVIDENCE: 1. Staff 1 used profane language toward resident 1 on 7/9/2019 and reported it to the administrator of the facility later that day. It was not reported to Adult Protective Services. This was revealed in interviews with staff 1 and the administrator.
Plan of Correction:	North Roanoke Assisted Living will comply with 63.2-(16)-1606-BA. NRAL will act in accordance with code 63.2-(16)-1606-BA to inform the local social services or the adult protective services of an incident of suspected abuse. NRAL conducted additional trainings with the identified employee that included human rights and confidentially and boundaries. The identified employee was also informed about the mandated reporting. NRAL will continue to provide ongoing training for all employees as it relates to Resident Rights and Mandated Reporting. This plan of correction is submitted as required under State and Federal law. The submission of this Plan of Correction does not constitute an admission on the part of North Roanoke Assisted Living as to the accuracy of the surveyor?s findings or the conclusions drawn therefrom. Submission of this Plan of Correction also does not constitute an admission that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the North Roanoke Assisted Living?s policies and procedures should be considered subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence and any corresponding state rules of civil procedure and should be inadmissible in any proceeding on that basis. North Roanoke Assisted Living submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against North Roanoke Assisted Living or any employee, agent, officer, director, attorney, or shareholder of North Roanoke Assisted Living.