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: Oct. 24, 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

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/24/2022 from 09:00 AM until 02:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on observation during medication cart audit, the facility failed to implement their infection control policy regarding blood glucose monitoring. EVIDENCE: 1. The facility?s medication management plan/infection control policy provided during on-site inspection on 10/24/2022, included the following: ?15. Blood Glucose Monitoring In service training for staff related to infection control practices will include the following: B. Glucometers will be cleaned and disinfected after each use with alcohol swabs. Each resident shall have their own Glucometer which will be appropriately labeled with the resident?s name.? and ?Blood Glucose Monitoring Policy ? North Roanoke Assisted Living Facility Blood Glucose Monitoring Devices Policy follows the CDC guidelines and the Virginia Health Department regulations.? 2. During audits of the medication carts located on unit 4, it was noted by collateral 1 that the glucometers for residents 1 and 2 were not labeled with the residents? names. Also, the glucometer bag that was labeled for resident 3 contained a glucometer unit that was not labeled for resident 3.
Plan of Correction:	Corrective Action(s): a. The residents identified in the violation notice have been addressed and corrected. As evident the corrections were made during the licensing inspection. Furthermore, all residents' glucometers and glucometer bags have been properly labeled. The facility will follow the medication management plan, with methods to ensure that the resident's medications ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Those issues related to medication administration are communicated to the prescribing physician and verifying orders that are accurately transcribed to the MARs. Registered Mediation Aides (RMA) will continue to notify the doctor and document efforts to make sure the residents medications are filled and refilled. Actions to prevent recurrence: a. The medication carts will be audited (Please See Attachment) by the Unit Managers to ensure that all medications are within date. Frequency of audits can be weekly, bi-weekly, or monthly determined by the oversight of a RN Director of Nursing Medication Compliance. b. The RMA's will receive in-service training on the importance of double- checking the med cart for cleanliness and organization and to ensure all supplies are replenished on the cart. c. The Medication Compliance Consultant, Unit Manager and Registered Medication Aide will conduct a routine audit (Please See Attachment) of accu-check and medications that require labeling for dates and prescribed duration times. Monitoring/Oversight Procedures: a. The Unit Manager/Registered Medication Aides will be responsible for routine audits of the med carts. b. The medication reviews will be conducted by a licensed professional annually. A medication refresher training was completed for all current registered medication aides.
Standard #:	22VAC40-73-640-A
Description:	Based on observation during the medication cart audit, resident record review, and staff interview, the facility failed to implement their medication management plan. EVIDENCE: 1. The facility?s medication management plan provided during on-site inspection on 10/24/2022 contained documentation on page 1 that the facility will maintain an adequate supply of medications at all times. 2. The record for resident 6 contained a physician?s order, dated 01/05/2022, for Clotrimazole 1% cream apply two times daily. The October 2022 medication administration record (MAR) for the resident indicated that the aforementioned medication was not administered on 10/22/2022 and 10/23/2022 due to ?waiting on pharmacy?; however, interview with staff 2 indicated that the medication was not located in the medication cart and that she would have to reorder it. At 09:55AM on 10/24/2022, staff 2 had documented on the resident 6 MAR that she had re-ordered the medication on this date.
Plan of Correction:	Corrective Action(s): a. The residents identified in the violation notice have been addressed and corrected. As evident the corrections were made during the licensing inspection. Furthermore, all residents' glucometers and glucometer bags have been properly labeled. The facility will follow the medication management plan, with methods to ensure that the resident's medications ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Those issues related to medication administration are communicated to the prescribing physician and verifying orders that are accurately transcribed to the MARs. Registered Mediation Aides (RMA) will continue to notify the doctor and document efforts to make sure the residents medications are filled and refilled. Actions to prevent recurrence: a. The medication carts will be audited (Please See Attachment) by the Unit Managers to ensure that all medications are within date. Frequency of audits can be weekly, bi-weekly, or monthly determined by the oversight of a RN Director of Nursing Medication Compliance. b. The RMA's will receive in-service training on the importance of double- checking the med cart for cleanliness and organization and to ensure all supplies are replenished on the cart. c. The Medication Compliance Consultant, Unit Manager and Registered Medication Aide will conduct a routine audit (Please See Attachment) of accu-check and medications that require labeling for dates and prescribed duration times. Monitoring/Oversight Procedures: a. The Unit Manager/Registered Medication Aides will be responsible for routine audits of the med carts. b. The medication reviews will be conducted by a licensed professional annually. A medication refresher training was completed for all current registered medication aides.
Standard #:	22VAC40-73-680-B
Description:	Based on observation the facility failed to ensure that medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. EVIDENCE: At 09:23 AM on the date of inspection, while performing a physical plant walk-through, LI and collateral 1 observed an oval, clear, red pill on the hallway floor outside of room 305.
Plan of Correction:	Corrective Action(s): a. The residents identified in the violation notice have been addressed and corrected. As evident the corrections were made during the licensing inspection. Furthermore, all residents' glucometers and glucometer bags have been properly labeled. The facility will follow the medication management plan, with methods to ensure that the resident's medications ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Those issues related to medication administration are communicated to the prescribing physician and verifying orders that are accurately transcribed to the MARs. Registered Mediation Aides (RMA) will continue to notify the doctor and document efforts to make sure the residents medications are filled and refilled. Actions to prevent recurrence: a. The medication carts will be audited (Please See Attachment) by the Unit Managers to ensure that all medications are within date. Frequency of audits can be weekly, bi-weekly, or monthly determined by the oversight of a RN Director of Nursing Medication Compliance. b. The RMA's will receive in-service training on the importance of double- checking the med cart for cleanliness and organization and to ensure all supplies are replenished on the cart. c. The Medication Compliance Consultant, Unit Manager and Registered Medication Aide will conduct a routine audit (Please See Attachment) of accu-check and medications that require labeling for dates and prescribed duration times. Monitoring/Oversight Procedures: a. The Unit Manager/Registered Medication Aides will be responsible for routine audits of the med carts. b. The medication reviews will be conducted by a licensed professional annually. A medication refresher training was completed for all current registered medication aides.
Standard #:	22VAC40-73-750-D
Description:	Based on observation, the facility failed to provide adequate and accessible closet space for each resident. EVIDENCE: In room 291, LI and collateral 1 observed that the closet for the room did not contain a rod for the two occupants to hang their clothing or other items.
Plan of Correction:	Corrective Action(s): a. The items identified in the violation notice regarding the building/grounds/rooms have been placed on a list for the Maintenance department to repair and/or replace. Please note that the items that were Please note that this is an ongoing process and there will be continuous efforts to ensure the interior as well as the exterior of all buildings are maintained including the furnishings and equipment. Actions to prevent recurrence: a. An additional Maintenance personnel was hired on 11/18/2022 due to the size of facility and the population of residents we serve to assist with handling the ongoing maintenance requirements. Monitoring/Oversight Procedures: a. The Unit Manager, Housekeepers, and all direct care/nursing staff will be responsible for identifying items and/or areas that need repairs and reporting promptly any maintenance issues to their supervisors and then to the Maintenance Department, Site Administrator and/or Assistant Administrators. The documentation will be kept in Site Administrator office. Housekeeping checklists (Please See Attachment) will be reviewed weekly to identify and report to management physical and/or environmental concerns. b. Review of this process will be monitored by the management team as needed.
Standard #:	22VAC40-73-750-E
Description:	Based on observation, the facility failed to have sufficient bed linens in good repair. EVIDENCE: While observing room 183, LI and collateral 1 observed that the pillow on one of the beds had an exterior that was stained and cracked.
Plan of Correction:	Corrective Action(s): a. The items identified in the violation notice regarding the building/grounds/rooms have been placed on a list for the Maintenance department to repair and/or replace. Please note that the items that were Please note that this is an ongoing process and there will be continuous efforts to ensure the interior as well as the exterior of all buildings are maintained including the furnishings and equipment. Actions to prevent recurrence: a. An additional Maintenance personnel was hired on 11/18/2022 due to the size of facility and the population of residents we serve to assist with handling the ongoing maintenance requirements. Monitoring/Oversight Procedures: a. The Unit Manager, Housekeepers, and all direct care/nursing staff will be responsible for identifying items and/or areas that need repairs and reporting promptly any maintenance issues to their supervisors and then to the Maintenance Department, Site Administrator and/or Assistant Administrators. The documentation will be kept in Site Administrator office. Housekeeping checklists (Please See Attachment) will be reviewed weekly to identify and report to management physical and/or environmental concerns. b. Review of this process will be monitored by the management team as needed.
Standard #:	22VAC40-73-870-A
Description:	Based on observation during a tour of the facility?s physical plant, the facility failed to ensure the interior of the building was maintained in good repair, 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 resident 4?s room was noted to have pieces of linoleum peeling away from the floor and the handicapped grab bar around the toilet was noted to have multiple areas of a brown stain. Also, the floor around the resident?s bed was noted to have a large area of black, sticky substance. 3. The floor around resident 5?s bed was noted to have a large area containing a black, sticky substance. Also, the central air unit mounted to the wall under the resident?s window was noted to be missing both knobs to function the unit. 4. Room 183 contained the following: multiple brown spots on the walls in the bedroom and the bathroom, multiple stains on the floor in the bedroom and in the bathroom, a shower mat and wash cloth on the grab bar in the bathroom that contained multiple brown stains, the vanity in the bathroom contained multiple brown stains, both the wall around the light switch cover and the light switch cover itself in the bathroom were covered in multiple brown stains. 5. A ceiling tile located outside of rooms 243 and 249 was observed by collateral 1 to have a small hole with a slow water drip and a small puddle of water was observed under the ceiling tile on the floor in the hallway. 6. A baseboard/trim was observed by collateral 1 as peeling from the wall in the hallway outside of room 228. 7. The anti-slip floor strips were noted to be peeling off the floor on the ramp in unit 4 and on the ramp between units 3 and 4. The ramp between units 3 and 4 were noted to have broken tiles. 8. At approximately 9:18AM during on-site inspection on 10/24/2022, a medium size brown bug was noted to be crawling in the bathroom by the bathtub in room 291 and was then noted to crawl under the wall in the bathroom near the bathroom door. Two dead small sized brown bugs were noted to be floating in the standing water of the bathtub of room 291. 9. At 09:20 AM, LI observed that room 291 had a large gap (approximately 1 to 2 inches) at the bottom of the door which led to the outdoors. The edge of the door near the knob had a brown build-up. The radiator cover in room 291 was being held together by silver 3M tape. 10. In units 2 and 4, the hallway floors had a brown build-up around the edges of the doors. 11. At 09:54 AM, the floor in room 277 was observed by LI as being covered with a brown and gray substance next to the resident beds. 12. At 09:24 AM, the bathroom tile around and next to the toilet of room 296 was observed by LI to be cracked. 13. At 10:30 AM, LI and collateral 1 observed numerous bed frames and head and foot boards stacked on their sides in the common area of unit 3.
Plan of Correction:	Corrective Action(s): a. The items identified in the violation notice regarding the building/grounds/rooms have been placed on a list for the Maintenance department to repair and/or replace. Please note that the items that were Please note that this is an ongoing process and there will be continuous efforts to ensure the interior as well as the exterior of all buildings are maintained including the furnishings and equipment. Actions to prevent recurrence: a. An additional Maintenance personnel was hired on 11/18/2022 due to the size of facility and the population of residents we serve to assist with handling the ongoing maintenance requirements. Monitoring/Oversight Procedures: a. The Unit Manager, Housekeepers, and all direct care/nursing staff will be responsible for identifying items and/or areas that need repairs and reporting promptly any maintenance issues to their supervisors and then to the Maintenance Department, Site Administrator and/or Assistant Administrators. The documentation will be kept in Site Administrator office. Housekeeping checklists (Please See Attachment) will be reviewed weekly to identify and report to management physical and/or environmental concerns. b. Review of this process will be monitored by the management team as needed.
Standard #:	22VAC40-73-870-E
Description:	Based on observation during a tour of the facility?s physical plant, the facility failed to ensure that all furnishings, fixtures, and equipment shall be kept clean and in good repair and condition. EVIDENCE: 1. At 9:19 AM during the on-site inspection on 10/24/2022, it was observed by collateral 1 that the bathtub in room 291 was half way full of water due to the drain being clogged. At 10:38 AM, it was observed by collateral 1 that the bathtub had been unclogged; however, the tub contained a black film and when water was ran into the bathtub, the drain was still clogged. 2. At 09:24 AM, LI and collateral 1 observed that the shelf under the bathroom sink of room 296 was collapsed with several personal hygiene products stacked on the collapsed shelf. 3. At 09:25 AM, LI observed that the shower chair in room 296 had a dark-colored stain across the seat and the bottom of the bathtub was cracked.
Plan of Correction:	Corrective Action(s): a. The items identified in the violation notice regarding the building/grounds/rooms have been placed on a list for the Maintenance department to repair and/or replace. Please note that the items that were Please note that this is an ongoing process and there will be continuous efforts to ensure the interior as well as the exterior of all buildings are maintained including the furnishings and equipment. Actions to prevent recurrence: a. An additional Maintenance personnel was hired on 11/18/2022 due to the size of facility and the population of residents we serve to assist with handling the ongoing maintenance requirements. Monitoring/Oversight Procedures: a. The Unit Manager, Housekeepers, and all direct care/nursing staff will be responsible for identifying items and/or areas that need repairs and reporting promptly any maintenance issues to their supervisors and then to the Maintenance Department, Site Administrator and/or Assistant Administrators. The documentation will be kept in Site Administrator office. Housekeeping checklists (Please See Attachment) will be reviewed weekly to identify and report to management physical and/or environmental concerns. b. Review of this process will be monitored by the management team as needed.
Standard #:	22VAC40-73-925-A
Description:	Based on observation the facility failed to ensure soap was accessible to each face/hand washing sink. EVIDENCE: 1. While performing a physical plant tour at 10:58AM on 10/24/2022, it was observed by LI and collateral 1 that there was no soap accessible to the face/hand washing sink in resident 4?s room. 2. At 09:20 AM, LI and collateral 1 interviewed resident 7 and were told that his bathroom, room 291, has not had hand soap for ?a while?.
Plan of Correction:	Corrective Action(s): a. The items identified in the violation notice regarding the building/grounds/rooms have been placed on a list for the Maintenance department to repair and/or replace. Please note that the items that were Please note that this is an ongoing process and there will be continuous efforts to ensure the interior as well as the exterior of all buildings are maintained including the furnishings and equipment. Actions to prevent recurrence: a. An additional Maintenance personnel was hired on 11/18/2022 due to the size of facility and the population of residents we serve to assist with handling the ongoing maintenance requirements. Monitoring/Oversight Procedures: a. The Unit Manager, Housekeepers, and all direct care/nursing staff will be responsible for identifying items and/or areas that need repairs and reporting promptly any maintenance issues to their supervisors and then to the Maintenance Department, Site Administrator and/or Assistant Administrators. The documentation will be kept in Site Administrator office. Housekeeping checklists (Please See Attachment) will be reviewed weekly to identify and report to management physical and/or environmental concerns. b. Review of this process will be monitored by the management team as needed.
Standard #:	22VAC40-73-925-B
Description:	Based on observation the facility failed to ensure common face/hand washing sinks had paper towels or an air dryer. EVIDENCE: 1. During a tour of the facility?s physical plant, at 10:58AM on 10/24/2022, it was observed by LI and collateral 1 that there were no paper towels nor an air dryer accessible to the face/hand washing sink in resident 4?s room. 2. At 09:20 AM, LI and collateral 1 interviewed resident 7 and observed that there were no paper towels, hand towels, nor an air dryer.
Plan of Correction:	Corrective Action(s): a. The items identified in the violation notice regarding the building/grounds/rooms have been placed on a list for the Maintenance department to repair and/or replace. Please note that the items that were Please note that this is an ongoing process and there will be continuous efforts to ensure the interior as well as the exterior of all buildings are maintained including the furnishings and equipment. Actions to prevent recurrence: a. An additional Maintenance personnel was hired on 11/18/2022 due to the size of facility and the population of residents we serve to assist with handling the ongoing maintenance requirements. Monitoring/Oversight Procedures: a. The Unit Manager, Housekeepers, and all direct care/nursing staff will be responsible for identifying items and/or areas that need repairs and reporting promptly any maintenance issues to their supervisors and then to the Maintenance Department, Site Administrator and/or Assistant Administrators. The documentation will be kept in Site Administrator office. Housekeeping checklists (Please See Attachment) will be reviewed weekly to identify and report to management physical and/or environmental concerns. b. Review of this process will be monitored by the management team as needed.
Standard #:	22VAC40-73-930-B
Description:	Based on observation and staff interview, the facility failed to ensure the signaling device that terminates at a central location 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; however, through an interview with staff 2 it was confirmed that the medication room/nurses? station is not continuously staffed. There are no individual lights or audible indicators in the hall outside residents? bedrooms. 2. Resident 5?s room did not contain a signaling device in her bedroom or in her bathroom that alerts direct care staff if she needs assistance.
Plan of Correction:	Corrective Action(s): a. The items identified in the violation notice regarding the signaling and call systems have been placed on a high priority list for repair and/or replacement. Please note that this is an ongoing process and there will be continuous efforts to ensure the signaling and call systems. (Please See Attachment) regarding the initial quote received to improve/upgrade the facility's signaling and call systems. This quote is substantially more than what the facility is able to afford at this time. However, the facility's licensee is actively searching for a better and affordable solution for the signaling and call systems. North Roanoke Assisted Living appreciates the patience and understanding from the Piedmont Licensing Department on this matter as we continue to strive towards becoming compliant with this identified standard. Actions to prevent recurrence: b. Insert response for actions to prevent recurrence for signaling and call systems. Monitoring/Oversight Procedures: a. Insert monitoring and oversight procedures for the signaling and call systems. b. Review of this process will be monitored by the management team as needed