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 6, 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 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

Technical Assistance:

The licensing inspectors and the administrator discussed standards 980-C and 50-A.

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: 7/6/2022, 8:00 am to 5:05 pm. with two licensing inspectors. 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: 118 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 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 Susan Mallory, Licensing Inspector at (540) 309-3043 or by email at susan.mallory@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on observation during medication cart audit, document review and staff interview, the facility failed to implement their infection control policy regarding blood glucose monitoring. EVDIENCE: 1. The facility?s infection control policy provided by the facility during on-site inspection on 7/06/2022 indicated the following regarding blood glucose monitoring: ?Each resident requiring the use of a blood monitoring machine will have their own machine and lancet device. There will be no sharing of devices or machines.? 2. During audits of medication carts 2A, 2B and 2C, it was noted by one licensing inspector (LI) that there were multiple glucometers lying lose in the top right hand drawer of each cart and some glucometers not labeled with the residents? names. Interview with staff 1 revealed that all of the glucometers? batteries were dead and that direct care staff have been using one glucometer to test the blood sugar for all the residents requiring blood glucose checks. Staff 1 showed the LI the OneTouch Ultra 2 glucometer that staff have been using for the residents.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-210-D
Description:	Based on staff record review and staff interview, the facility failed to ensure a registered medication aide (RMA) had the continuing education required by the Virginia Board of Nursing. EVIDENCE: 1. The Virginia Board of Nursing indicates, according to 18VAC90-60-100, the following: ?B. Continuing education required for renewal. 1. In addition to hours of continuing education in direct care required for employment in an assisted living facility, a medication aide shall have the following: a. Four hours each year of population-specific training in medication administration in the assisted living facility in which the aide is employed; or b. A refresher course in medication administration offered by an approved program.? 2. The record for staff 1, date of hire 02/03/2017, did not contain documentation of the staff member having the required annual 4 hour refresher for the training year 02/03/2021 through 02/02/2022. Interview with staff 6 confirmed this was accurate.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-B
Description:	Based on resident record review and staff interview, the facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually for each resident. EVIDENCE: 1. The following document, ?Report of TB Screening?, was located in the following residents? records: resident 3, dated 01/02/2021; resident 5, dated 04/15/2021 and resident 8, dated 10/02/2020. Therefore, the aforementioned residents have not had a TB risk assessment completed annually. Interview with staff 1 confirmed this was accurate.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to update the individualized service plan (ISP) as needed for a significant change of a resident?s condition. EVIDENCE: 1. The record for resident 7 contained a physician?s order, dated 05/10/2022, for Ted Knee Hi Hose (1 pair) Place on in the AM and remove at Bedtime for edema. The ISP for the resident, dated 08/24/2021, did not include that the resident wears Ted Hose.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-460-B
Description:	Based on resident record review, the facility is not providing some care or services. EVIDENCE: 1. Resident 2 receives DAP funding, and the DAP contract with the facility specifies conflicting requirements: a.) This person should be in a unit with a staff to resident ration of 1:2 during the day and 1:4 overnight, with 15 minute checks; b.) a ratio of 1:5 during the day and 1:4 overnight, with 15 minute checks; and c.) a ratio of 1:10. The facility is routine staffed with 3 to 4 direct care staff, and usually has over 100 residents.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-530-C
Description:	Based on observation and interview, the facility failed to provide freedom of movement for the resident to common areas and to their personal spaces. EVIDENCE: 1. Room 204 was locked and residents 12 and 22 were unable to get in. 2. At 10:10 am staff 7 unlocked the door and stated that the rooms were ?locked when floors [were] wet?. The bedroom floor was wet. Staff 7 stated that someone in housekeeping locked the doors. Other doors in the vicinity of room 204 were also locked.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-640-A
Description:	Based on document review, the facility failed to implement a section of their medication management plan. EVIDENCE: 1. The facility?s medication management plan states in the ?Methods to ensure accurate counts of all controlled substances? section, ?Our medication narcotic count will be done and signed at shift change or at time they are counted?, and ?Unit managers and Director of Nursing Compliance will monitor signatures with oversite or review done by Nurse Consultant.? 2. The CONTROLLED DRUGS ? COUNT RECORD for cart 4B on unit 4 for July 2022 shows only one day completed with initials for counts, and the date is not clear, For cart 4C the first two lines of the form and part of the third line have been filled out, and the dates are not clear. For the same form for cart 4C for June 2022 the counts were completed for the top 26 lines, and the dates are unclear. These omissions were noted on 7/6/2022.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-650-E
Description:	Based on resident record review, the facility failed to have a signed physician order in a resident file. EVIDENCE: 1. Resident 1 has an order signed 3/23/2022 for Systane Eye Drops to be administered to the right eye every two hours as needed, and this is not on the medication administration record (MAR). There is no discontinue order. 2. Resident 1 has an order signed 3/23/2022 for Albuterol/Ipratropium Bromide 2.5-0.5/3 nebulizer to be administered 4 times daily as needed, and this is not on the MAR and there is no discontinue order.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and interview, the facility failed to administer medication as ordered, and to follow the curriculum for registered medication aides. EVIDENCE: 1. Resident 1 has an order signed 3/23/2022 for Clotrimazole 1% cream, and it is not in the facility, nor is there a discontinue order. The July medication administration record (MAR) Clotrimazole/Betamethone 1-0.05% cream is being administered instead, and the resident file does not have an order for this. 2. In an interview with staff 1, it was discovered that blood glucose monitoring, a component of the Registered Medication Aide (RMA) curriculum (Section 8.4) approved by the Board of Nursing, was being done by direct care staff (not RMAs), and entered into the electronic medication administration record (MAR) by the RMA.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-E
Description:	Based on observation, resident interview and resident record review, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber were provided according to his instructions and documented. EVIDENCE: 1. The record for resident 7 contained a physician?s order, dated 05/10/2022, for Ted Knee Hi Hose (1 pair) Place on in the AM and remove at Bedtime for edema. 2. One licensing inspector (LI) observed staff 1 administer resident 7?s medication during the morning medication pass on day of inspection and the LI noted that on the electronic medication administration record (EMAR) for the resident the aforementioned Ted Hose order was included. When the LI questioned staff 1 about the resident?s Ted Hose staff 1 stated that the resident was already wearing her Ted Hose. 3. The LI interviewed resident 7 at 9:07 AM and the resident stated that she was not wearing Ted Hose and the LI observed this. Resident 7 stated that she hasn?t had her Ted Hose on for ?awhile? and she believes that they are lost. 4. The July 2022 EMAR for the resident included staff 1?s initials as having put on the resident?s Ted Hose on 07/06/2022 at 8:00AM.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-M
Description:	Based on observation, resident record review and staff interview, the facility failed to ensure that medications ordered for PRN (as needed) administration were available at the facility. EVIDENCE: 1. The record for resident 5 contained a physician?s order, dated 04/12/2022, for Ramelteon for insomnia to nightly regimen and the July 2022 medication administration record (MAR) contained Ramelteon 8 mg tablet at bedtime as needed for sleep. During medication cart audit this medication could not be located by staff 1 and stated that it was not in the facility for the resident.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-750-D
Description:	Based on observation, the facility failed to provide space to hang up clothes in a resident bedroom. EVIDENCE: 1. In room 291, there is no place to hang up clothes on clothes hangers. There were no closet rods in the closet.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-750-E
Description:	Based on observation, the facility failed to ensure that residents always had clean sheets. EVIDENCE: 1. A resident in room 291 was observed sleeping on a bed with no sheets. 2. A bed in room 183 has no sheets, just a bedspread.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-A
Description:	Based on observation during a tour of the physical plant, the facility failed to ensure the interior of the building was maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. The ramp located in the hallway by room 199 was noted to have multiple pieces of flooring missing. 2. The bathroom floor around the toilet in room 178 (resident 20) was noted to have pieces of linoleum peeling away from the floor. Also, the floor around the resident?s bed was noted to have a large black, sticky substance. 3. The floor around the resident?s bed in room 182 (resident 5) was noted to have a large black, sticky substance. Also, the shower curtain the resident 5?s shower contained numerous brown spots. 4. Room 183 contained the following: multiple brown spots on the walls in the bedroom, the floor beside the bed close to the window contained a large black spot/substance and contained two playing card stuck to the floor and the door to the bathroom and the hallway contained a large brown substance around the edge/frame of the door where the door knobs are located. 5. A ceiling tile located outside of rooms 243 and 249 was observed by two licensing inspectors to have a small hole with a slow water drip and a puddle of water was observed under the ceiling tile on the floor in the hallway. 6. A baseboard/trim was observed by two licensing inspectors as peeling from the wall in the hallway outside of room 228. 7. The anti-slip floor strips are coming off the floor in a ramp in unit 4 and on the ramp between units 3 and 4. The ramp between units 3 and 4 has broken tiles. 8. There are dried spills on the floor on unit 3 near rooms 220 and 225. 9. In the hall outside room 202 two ceiling light covers are cracked and one is missing a piece. Some objects that looked like dead bugs were noticed inside the covers. 10. Room 312 had debris on the floor and the floor looked dirty under the beds and around the edges. 11. In unit 4, the hall floors had a dirt buildup near the edges of the doors and the metal strips. 12. Room 291 had a large gap (approximately 1 to 2 inches) at the bottom of the door to the outdoors. The edge of this door near the knob had a build-up of brownish dirt. The radiator cover in room 291 was coming off.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-B
Description:	Based on observation during a tour of the physical plant, the facility failed to ensure the building was free from foul, stale, and musty odors. EVIDENCE: 1. During on-site inspection, one licensing inspector (LI) noted that the bathroom of room 253 contained a strong stale/musty smell which was also noted by resident 21.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-E
Description:	Based on observation during a tour of the physical plant, the facility failed to ensure all fixtures were in good repair and condition. EVIDENCE: 1. During on-site inspection, one licensing inspector (LI) observed the sink in resident 2?s bathroom to continue running even when both the hot and cold water knobs had been completely cut off. 2. The tub in room 291 had dripping water from the tap. In the same room, the toilet was not clean, and there was water on the floor. 3. Rooms 287 and 291 had broken blinds. 4. In the bathroom of room 291, the sink had brownish dirt or stains, the shower curtain had brown stains at the bottom of it, and the grout in the tub was discolored with brownish-grey stains.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-925-A
Description:	Based on observation, the facility failed to ensure that there was soap in a bathroom. EVIDENCE: 1. The bathroom in room 291 had no soap at the face/handwashing sink.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-925-B
Description:	Based on observation, the facility failed to ensure that there was paper towels or an air dryer in common bathroom. EVIDENCE: 1. The bathroom in room 312, shared by more than one resident, had no paper towels or air dryer at the face/handwashing sink.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-930-B
Description:	Based on observation, the facility failed to have a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal. EVIDENCE: 1. In unit 4, the signaling devices terminate in the medication room/nurses station, and it was observed to be not continuously staffed. 2. The terminus of the signaling devices on unit 4 lacks room numbers on some of the lights, preventing staff from knowing what room was signaling. Staff 3 saw a light going off and didn?t know what room it came from. There are no individual lights in the hall outside resident bedrooms. 3. Resident 5?s room did not contain a signaling device in her bedroom or in her bathroom that alerts direct care staff that she needs assistance. There was a blank plate on the wall in the location where other rooms had a signaling device.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-940-A
Description:	Based on document review, the facility failed to obtain an annual fire inspection. EVIDENCE: 1. The most recent fire inspection is dated 11/6/2020.
Plan of Correction:	Not available online. Contact Inspector for more information.