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 21, 2021 and July 22, 2022

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 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Technical Assistance:

The LI explained reg. 680-G: "Over the counter medication shall remain in the original container, labeled with the resident's name....", and that the facility can purchase over the counter medication from any source they choose - it is not required to be ordered from a pharmacy with a pharmacy label.

Comments:

A renewal inspection was initiated on 7/20/2021 and concluded on 7/22/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 114. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed five resident records, five staff records, activities calendar, staff schedules, inspection reports, policies submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 7/22/2021. An exit interview was conducted with the Administrator on the date of inspection and 7/230/2021, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on staff record review, the facility failed to ensure that a new direct care staff member had first aid training within the first 60 days of employment. EVIDENCE: 1. Staff 1 was hired on 5/19/2021 as of 7/20/2021 there is no documentation to support that this person had first aid training.
Plan of Correction:	Plan of Correction for Standard 22 VAC 40-73-(3)-260-A North Roanoke Assisted Living will comply with the Standard 22 VAC 40-73-(3)-260-A. North Roanoke Assisted Living will continue to ensure that new direct care staff members receive first aid training within the first 60 days of employment. The first aid training was previously scheduled but due to unforeseen circumstances it had to be rescheduled. The former employee was scheduled for CPR and First Aid on 7/23/2021 which was reported to the Licensing Inspector during the inspection. However, the former employee was relieved of all duties and responsibilities effectively on 7/23/2021. 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-C
Description:	Based on resident record review, the facility failed to address service needs on a comprehensive individualized service plan (ISP). EVIDENCE: 1. The physical for resident 1, dated 4/13/2021, shows this resident is allergic to beestings and poison oak. The ISP dated 5/7/2021 identifies the allergies, but does not show what services the facility will provide to avoid the allergens or what to do if they are encountered. 2. The uniform assessment instrument dated 12/17/2020 for resident 1 shows this resident is verbally abusive toward staff and peers. This behavior is not addressed on the ISP dated 5/7/2021.
Plan of Correction:	Plan of Correction Standard 22 VAC 40-73-(6)-450-C North Roanoke Assisted Living will comply with the Standard 22 VAC 40-73-(6)-450-C. North Roanoke Assisted Living will continue to ensure that all services needs are addressed in the individual service plan (ISP). The ISP identifies the allergies as stated in the description of violation and the facility stated on the ISP for the identified resident that he would be monitored & kept allergy free until or the ISP expiration date. The facility also has a physician order for EpiPen if the individual suffers from any allergic reaction. The facility believes that this is a technical matter and does not deserve to be a violation. Secondly, the UAI was done on 12/17/20 by the Rockbridge Area Community Services (RACS) case manager. The UAI indicates under the behavioral pattern section Abusive/Aggressive/Disruptive less than weekly is marked. The type of behavior states that he can be verbally abusive towards staff and peers and the source of information was the Manor of Natural Bridge Staff. Please note that the case manager completing the assessment received this information from a staff member(s) of the Manor of Natural Bridge Staff. This type of behavior was not observed by the assessor. Please note that the Manor of Natural Bridge is no longer open as an Assisted Living Facility. This facility closed their doors in April 2021 giving the residents a week?s notice to vacate the property. NRAL was contacted by the Manor of Natural Bridge on Monday, April 16, 2021 that they needed placement for several residents because they were closing their doors at the end of the week. NRAL worked extremely hard to ensure that all residents that were being admitted our facility was done professionally and thoroughly. The resident was admitted on under the emergency placement protocols. Furthermore, this resident has not demonstrated any of this type of behavior at our facility since his admission. NRAL will continue to monitor his behaviors until further notice. The facility also believes that this is a technical matter and does not deserve to be a violation. 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 resident record review, the facility failed to administer medication in accordance with the physician's instructions. EVIDENCE: 1. Resident 2 has a signed physician order for 51 units of Levemir Flextouch to be injected daily at bedtime. The order, signed on 7/21/2021, shows the original date of the prescription was 5/29/2018. The July 2021 medication administration record (MAR) shows this was not administered on 7/8, 9, 14, and 15/2021.The documented reason is "MEDICATION NOT GIVEN" with no explanation of why this was not given.
Plan of Correction:	Plan of Correction Standard 22 VAC 40-73-(6)-680-D North Roanoke Assisted Living will comply with the Standard 22 VAC 40-73-(6)-680-D. North Roanoke Assisted Living will continue to abide with standard as it relates to medications being administered in accordance with the physician's or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. NRAL has reviewed the facility?s E-MAR Policy with registered medication aides and nurses as it relates to the medication exceptions to ensure that the appropriate documentation with explanation is provided. 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-I
Description:	Based on resident record review and interview, the facility failed to correctly document a medication administration record (MAR). EVIDENCE: 1. The MAR for resident 5 shows that on July 3, 4, 5, 9, 10, 14, 15, 16, 18, and 19 an annual flu shot was given. The entries are not circled and do not include explanations as to why the annual injection was given or not given. An interview with staff 6 reveals that there is a glitch in the E-MAR system and documentation was provided to show the shot was actually given on 4/12/2021 by a nurse.
Plan of Correction:	Plan of Correction Standard 22 VAC 40-73-(6)-680-I North Roanoke Assisted Living will comply with the Standard 22 VAC 40-73-(6)-680-I. North Roanoke Assisted Living will continue to adhere to the standard as it relates to Medication Administration Record (MAR). As stated in the VDSS violation notice that the proper documentation was provided for the licensing inspector that the annual flu vaccine (only given once a year) was given by a Registered Nurse on 4/12/21. North Roanoke Assisted Living will continue to administer medication in accordance with the physician's or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. NRAL has reviewed the facility?s E-MAR Policy with the registered medication aides and nurses as it relates to the medication exceptions to ensure that the appropriate documentation with explanation is provided. 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 #:	22VAC40-73-860-J
Description:	Based on observation, the facility failed to ensure that a resident stored a cleaning supply in an out-of-sight place. EVIDENCE: 1. Room 304 had a bottle of rubbing alcohol stored on the window sill, where it was visible.
Plan of Correction:	Plan of Correction Standard 22 VAC 40-73-(8)-860-J North Roanoke Assisted Living will comply with the Standard 22 VAC 40-73-(8)-860-J. North Roanoke Assisted Living will continue to abide by the standard that allows our resident(s) to keep their own cleaning supplies or other hazardous materials in an out-of-sight place in his room if the resident does not have a serious cognitive impairment. The cleaning supplies or other hazardous materials shall be stored so that they are not accessible to other residents. However, the item which is a bottle of rubbing alcohol was cited as a cleaning product though it is used for personal care by the resident. The resident stated to the Administrator that it is used after he shaves his face and/or head to avoid getting razor bumps. This was also explained to the licensing inspector on the day of the inspection as it relates to the use of the rubbing alcohol. The facility believes that this is a technical matter and does not deserve to be a violation. 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 #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to maintain the building in good repair. EVIDENCE: 1. A ceiling pipe outside room 168 leaked drops of water, creating a small puddle on the floor. 2. The shower stall in room 177 was stained and the shower curtain was not clean. 3. The vent across from room 286 had a buildup of dust. 4. The floor in the hall near room 232 had worn spots that might cause a trip hazard.
Plan of Correction:	Plan of Correction Standard 22 VAC 40-73-(8)-870-A North Roanoke Assisted Living will comply with the Standard 22 VAC 40-73-(8)-870-A. North Roanoke Assisted Living will continue to act in accordance with the standard as it relates to the interior and exterior of all buildings being maintained in good repair and kept clean and free of rubbish. Please note that this is an ongoing process and there will be continuous efforts to take care the interior and exterior of all buildings are maintained. The ceiling pipe had been reported to the maintenance personnel and repairs were already scheduled. The shower stall, curtain and vent were cleaned immediately. The flooring (which is on Unit 3 that is currently an unoccupied unit with no residents allowed since February 2020) has been repaired from being a trip hazard. 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 #:	22VAC40-90-40-C
Description:	Based on staff record review, the facility employs a person who is ineligible for employment in an assisted living facility due to a felony conviction of a barrier crime. EVIDENCE: 1. The Virginia State Police criminal history record report shows staff 1 was convicted of a felony (18.2-77, burning or destroying a dwelling) on 11/27/2007. This is a barrier crime to employment in an assisted living facility.
Plan of Correction:	Plan of Correction for Standard 22 VAC 40-90-(BC3)-40-C North Roanoke Assisted Living will comply with the Standard 22 VAC 40-90-(BC3)-40-C. North Roanoke Assisted Living will continue to review the employees criminal history record report from the Virginia State Police to ensure that it abides by the barrier crimes for licensed assisted living facilities. Furthermore, the facility will like to note that the employee was approved for her initial license as a certified nurse aide (CNA) on 11/20/2019 by the Virginia Department of Health Professions. Additionally, when conducting a license look up there was no Additional Public Information* available in reference to any barrier crimes. The explanation of the * indicates that if "Yes" means that there is information the Department must make available to the public pursuant to ?54.1-2400.2.H of the Code of Virginia; please note that this may also include proceedings in which a finding of ?no violation? was made. For additional information click on the "Yes" link above. If "No" means no documents are available. Therefore, if the Virginia Department of Health Professions and Virginia Board of Nursing who require criminal background records to make a determination in reference to her approval to practice as a Certified Nurse Aide. The question that is posed is ?Why does this former employee be continuously reminded of a conviction that occurred over 14 years ago?? Also, please note that that while employed the former employee provided exceptional care to all of the residents that were under their supervision. The employee was relieved of all duties and responsibilities effectively on 7/23/2021. 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. The employee was relieved of all duties and responsibilities effectively on 7/23/2021.