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 24, 2019

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 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 SANCTIONS.

Technical Assistance:

860-D - residents should be reminded to close their room doors when they exit their room to help with heating/cooling and to deter insects; 450-F requires that Individualized Service Plans (ISP) be reviewed and updated at least once every 12 months and as needed as the condition of the resident changes; 200-B requires that staff perform services within their scope of practice and training. If there are services provided by direct care staff beyond the scope of their training (CNA or DCA) there must be documented training in the area of the service being provided.

Comments:

On 7/24/2019 two licensing inspectors and two consultants from the Division of Licensing Programs conducted a renewal study (8:30am to 5:20pm) for a facility currently on a provisional license. 146 residents were in care. Ten resident records were fully reviewed, five staff records were fully reviewed, and all new staff had background records checked. In addition, six resident records were partially reviewed. Two medication passes were observed. Three medication carts were checked. Residents were observed at a meal. A physical plant tour was done, and staff, residents, and others were interviewed. An exit interview was conducted with the Administrator, corporate nurse, licensee and the licensing inspectors and consultants on the date of inspection, where an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. The licensing team and facility management team discussed: dating menus; educating residents on the availability of snacks; methods of dealing with inaccurate uniform assessment instruments (UAI) and documentation associated with that; hypothetical situations when a resident refuses medication or treatments; methods of posting required documents so residents don't remove them; checking hot water temperatures; residents leaving doors open; staff vigilance to watch for names rubbing off of plastic bottles of over-the-counter medications; timely documentation of forms and resident records; cleaning surfaces during blood glucose monitoring; and where to find the UAI manual on the DSS website. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions, contact your licensing inspector at (540) 309-3043.

Violations:

Standard #:	22VAC40-73-260-C
Description:	Based upon observations and documentation, the facility failed to ensure that a listing of all staff that have current certification in CPR and first aid was posted in the facility so that the information is readily available to all staff at all times. EVIDENCE: 1. On 7/24/2019, the posted list of staff that have current certification in CPR and first aid did not include the following: staff 7 completed FA/CPR on 04/26/2019; staff 8 completed FA/CPR on 04/02/2019; staff 9 completed FA/CPR in 05/2019. .
Plan of Correction:	North Roanoke Assisted Living will comply with Standard 22VAC40-73-(3)-260-C as it relates to a listing of all staff that has current certification in first aid or CPR. North Roanoke Assisted Living will post the updated CPR and First Aide list in the facility. 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 #:	22VAC40-73-290-B
Description:	Based on observation, the facility failed to implement a procedure for posting the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public. EVIDENCE: 1. At the beginning of the inspection, the Administrator was in-charge, and his name was not posted identifying him as being in-charge.
Plan of Correction:	North Roanoke Assisted Living will comply Standard 22VAC40-73-(4)-290-B as it relates to the facility current on-site person in charge being posted in the facility. The administrator is the on site person in charge when he is at the facility. Furthermore, the designated person in charge when the administrator is not present is listed on the nursing schedule by day and shift which is posted in the facility in a conspicuous area. 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 #:	22VAC40-73-320-A
Description:	Based on review of resident records, the facility failed to obtain some required information on the pre-admittance physical. EVIDENCE: 1. The physical exam form for resident 6, dated 8/10/2018, shows this resident has an allergy to penicillin and the reactions to this are not listed. 2. The physical exam form for resident 6, dated 8/10/2018, lacks information regarding whether or not the resident can self-administer medications.
Plan of Correction:	North Roanoke Assisted Living will comply with Standard 22VAC40-73-(5)-320-A as it relates to the history and physical. The reaction is unknown for the allergy to penicillin. Furthermore, for the ability for the resident to be able to self administer or not self administer our facility does no allow self administration. All medications are administered complying with standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. 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 #:	22VAC40-73-380-A
Description:	Based on document review, the facility failed to obtain some required personal and social information on residents prior to or at the time of admission for three residents in the sample of ten. EVIDENCE: 1. Resident 3 was admitted to the facility on 07/09/2019. Name, address and telephone number of all legal representatives, if any; Name, address and telephone number of local department of social services agency, if applicable, and the name of the assigned case manager or caseworker; lifetime vocation, career, or primary role; and 19 - known allergies, if any were not addressed on the personal/social information sheet in the resident record. 2. Resident 8 was admitted to the facility on 04/30/2019. Allergies, lifetime vocation, career, or primary role and previous mental health or intellectual disability services history were not addressed on the personal/social information sheet in the resident record. 3. Resident 6 was admitted to the facility on 08/14/2018. Allergies, vocation, career, or primary role, previous mental health history, current behaviors, and substance abuse history were not addressed on the personal/social information sheet in the resident record.
Plan of Correction:	North Roanoke Assisted Living will comply with Standard 22VAC40-73-(5)-380-A as it relates to the resident?s personal and social information. North Roanoke Assisted Living will ensure that resident?s information will be documented on the facility?s social date form. Cited residents? personal and social information have been reviewed as well as updated. 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 #:	22VAC40-73-450-F
Description:	Based on document review, the facility failed to update the individualized service plan when the resident?s condition changed for one resident in a sample of ten. EVIDENCE: 1. The record for resident 6 contains physician?s orders dating back to April 2019 for weekly wound care, with the most recent dated 07/09/2019. The ISP for resident 6, dated 08/14/2018, has not been reviewed and updated to address these service needs.
Plan of Correction:	North Roanoke Assisted Living will comply with the Standard 22VAC40-73-(6)-450-F as it relates to individualized service plans. North Roanoke Assisted Living will review and update ISPs at least once every 12 months and/or as needed. 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 #:	22VAC40-73-610-B
Description:	Based on observation, the facility failed to have dates on the posted menu for meals and snacks. EVIDENCE: 1. Based on observation, the posted menu had no dates. It was labeled "Summer."
Plan of Correction:	North Roanoke Assisted Living will comply with the Standard 22VAC40-73-(6)-610-B as it relates to the menus for meals and snacks for the current week. North Roanoke Assisted Living will ensure that the menus will be dated and posted in an area conspicuous to residents. Also, menu substitutions or additions will be posted and all menus kept for two years. Furthermore, the facility ensures that all residents receive the adequate nutrition and offered seconds as it relates to the facility house diet which is approved by the resident?s medical doctor as well as dietician. Additionally, the facility also frequently offers thirds, fourths and fifths when available. 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 #:	22VAC40-73-680-D
Description:	Based on observations made during the 11am medication pass, the facility failed to ensure that medications were administered consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. During the 11am medication pass staff 2 did not wash or sanitize her hands prior to starting the medication pass. Staff 2 was observed administering medications to five different residents and she did not wash or sanitize her hands prior to or between administering medications to each of the five residents. The Commonwealth of Virginia Board of Nursing Medication Aide Curriculum for Registered Medication Aides basic guidelines for administering all medications (page 120) includes instructions to wash hands before and after administering a medication. 2. Staff 2 was observed performing a blood glucose monitoring test for resident 13 and she did not clean the top of the medication cart after placing the blood glucose monitor with a blood laden strip in the port on top of the cart prior to administering the next resident?s medication.
Plan of Correction:	North Roanoke Assisted Living will comply with the Standard 22 VAC 40-73-(6)-680-D as it relates to medications being administered in accordance with the physician's or other prescriber's instructions. North Roanoke Assisted Living will comply with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. 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 #:	22VAC40-73-680-E
Description:	Based on documentation review, the facility failed to provide medical treatments or procedures according to physician?s orders, and maintain documentation in the resident?s record. EVIDENCE: 1. Resident 6 has a physician?s order for Occupational Therapy dated 07/17/2019 and for daily lymphedema pumps to both lower extremities (BLE) for 30 minutes to 1 hour. There was no documentation that the pumps were being used daily and there was no documentation of an Occupational Therapy evaluation being scheduled or completed. 2. Supervisory staff stated that resident 6 had refused treatment and the refusals were documented in the refusal log or in another log. The inspector requested to review these logs but they were never produced.
Plan of Correction:	The facility did not submit a plan of correction for this violation.
Standard #:	22VAC40-73-680-G
Description:	Based on observation, the facility failed to have an over-the-counter medication labeled with the resident?s name. EVIDENCE: 1. The resident name had rubbed off a bottle of over-the-counter Norival, which was stored in medication cart 4D.
Plan of Correction:	North Roanoke Assisted Living will comply with the Standard 22VAC40-73-(3)-680-G as it relates to the over-the-counter medication. As cited the name had worn off and was corrected on site. Furthermore, the facility will continue to follow the standards as it relates to medication compliance. 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 #:	22VAC40-73-700-2
Description:	Based on observation, the facility failed to have a ?No Smoking ? Oxygen in Use? sign posted at a resident room that housed a resident that uses oxygen. EVIDENCE: 1. Resident 13 uses oxygen. The door or wall immediately near the door of the bedroom of resident 13 did not have a ?No Smoking ? Oxygen in Use? sign posted. The sign was posted down the hall from resident 13?s room.
Plan of Correction:	North Roanoke Assisted Living will comply Standard 22VAC40-73-(6)-700-2 as it relates to the posting of a "No Smoking-Oxygen in Use" sign. Additionally, the facility has "No Smoking-Oxygen in Use" sign posted throughout the building. North Roanoke Assisted Living will continue to enforce the smoking prohibition in any room of a building where oxygen is in use. 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.