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: Jan. 5, 2023

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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

50-A

Comments:

Type of inspection: Renewal and an Intensive Plan of Correction (IPOC) follow up. Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/05/2023 from 08:45 AM to 04:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the renewal inspection and IPOC follow up 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 observations of the facility medication carts, the facility failed to implement their infection control policy in regard to blood glucose monitoring. EVIDENCE: 1. The facility infection control policy indicates that ?North Roanoke Assisted Living will store unused supplies and medications in a clean area separate from used supplies and equipment?. 2. On the date of inspection, multi-stick penlets were observed by collateral 2 inside of the glucometer bags for residents 12, 13, 14, and 15 on the Unit 4D medication cart. 3. An interview with staff 2 expressed that the multi-stick penlets came in the bags with the glucometers and that the multi-stick penlets are not used but the glucometers are being used.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure that identified needs were addressed on individualized service plans (ISP). EVIDENCE: 1. The record for resident 4 has documentation under diet on a history and physical dated 09/08/2022 of small portions and avoid dry crumbly food. On the date of inspection, the ISP in the record for resident 4, dated 10/05/2022, did not address these identified needs. 2. The ISP dated 10/05/2022 in the record for resident 4 has documentation that the resident is disoriented to some spheres some of the time but does not identify what spheres are affected. 3. The record for resident 5 has a physician order dated 11/15/2022 for a double portion, avoid caffeine and tomato products, bedtime sandwich diet. On the date of inspection, the ISP in the record for resident 5, dated 05/06/2022, was not updated to address these identified needs.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-640-A
Description:	Based on observation during medication cart audits, the facility failed to implement a portion of its medication management plan. EVIDENCE: 1. The facility?s medication management plan states the following in regard to ensuring an accurate count of all controlled substances: ?our medication narcotic count will be done and signed at shift change or at time they are counted. Unit managers and Director of Nursing Compliance will monitor signatures with oversite of review done by Nurse Consultant.? 2. The Controlled Drugs-Count Record for medication carts 2A, 2B, 2C, 4A, 4B&D and 4C contained multiple dates, times and shifts that did not contain the signature of the medication staff that conducted the narcotic count with either the on-coming or off-going medication staff to verify that the count had been conducted. 3. The facility?s medication management plan states the following: ?weekly, all medications are checked for expiration dates, damage or contaminations by the Nurse and/or medication aide. If a medication is found to be outdated, discontinued, damaged or contaminated it will be properly pulled from the medication cart and destroyed. When a medication has been found to be outdated, the Nursing staff will contact the pharmacy for the medication to be reordered. 4. On the day of inspection (01/05/2023), the Lantus insulin pen located in medication cart 4C for resident 11 contained written documentation that the insulin pen was opened by staff on 12/01/2022 and that the insulin pen expired on 12/28/2022. 5. Interview with staff 2 confirmed there was not another Lantus insulin pen in the cart for the resident.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to ensure medications were administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 11/03/2022, for Lantus 20 units in the morning and to hold if blood sugar is less than 150 and an additional physician?s order, dated 11/03/2022, to increase Lantus to 20 units in the morning and continue Lantus every night and hold for blood sugar less than 150. The December 2022 and January 2023 medication administration records (MARs) for resident 1 indicates that the resident receives Lantus at 8:00AM and 8:00PM. For resident 1, the December 2022 MAR included the following blood glucose readings at 7:30AM: 12/02/2022 ? 145, 12/08-09/2022 ? 134, 12/12/2022 ? 137, and 12/20/2022 ? 145; however, the December 2022 MAR included signatures from medication staff that Lantus was administered to resident 1 on the aforementioned dates at 8:00AM when it should have been held due to the resident?s blood glucose being less than 150. The December 2022 and January 2023 MARs indicate that resident 1 was administered Lantus 20 units every night at 8:00PM; however, there was no documentation of what the resident?s blood sugar reading was prior to administering the insulin. 2. The record for resident 5 has documentation of a physician order for Humalog Kwikpen 100units/ml, inject 11 units subcutaneously with breakfast and lunch for DM II, hold if BS < 100 or patient does not eat. The December 2022 MAR for resident 5 has documentation that the residents blood sugar was 84 at 7:30am on 12/01/2022 and 60 at 7:30am on 12/21/2022. Staff initials are present for the administration of the Humalog Kwikpen 11 units on these dates and times and there is no documentation that the medication was held per physician orders. The record for resident 5 has documentation of a physician order for Humalog Kwikpen 100units/ml, inject 6 units SUB-Q at Dinner, hold if BS <100 or if patient does not eat. The December 2022 and January 2023 MAR for resident 5 has documentation of staff initials for administering this Insulin at 5:30pm from 12/01/2022 through 01/04/2023; however, there is no documentation of resident 5?s blood sugar being checked at this time to ensure that parameters are met for the administration of the medication. The December 2022 and January 2023 MAR for resident 5 has documentation that his blood sugars are checked at 7:30am, 11:30am and 7:30pm.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-E
Description:	Based on resident record and medication administration records (MARs) review, the facility failed to ensure that the results of medical procedures ordered by a physician were documented. EVIDENCE: 1. The record for resident 5 has documentation of a physician order to check blood sugars three times daily for DM. The December 2022 MAR for resident 5 does not have documentation of the results- of resident 5?s blood sugar check 7:30am on 12/14/2022 and 12/28/2022 and at 11:30am on 12/29/2022, 12/30/2022 and 12/31/2022. There is no documentation on the MAR to indicate why the blood sugars were not recorded.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-860-I
Description:	Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area. EVIDENCE: 1. At 8:57 am on the day of inspection 2 LI?s observed that the door to the kitchen across from Unit 2 was unlocked. A bottle of Boardwalk Germicidal Bleach, a bottle of Val-U-Chem Citrus + and a bottle of Val-U-Chem No Work Plus were observed sitting out in the dish washing area. A bottle of Strike Force Super Heavy Duty Cleaner/Degreaser, a bottle of Val-U-Chem Citrus +, and a bottle of NCL Bare Bones was observed sitting out on the bottom shelf of the kitchen storage/pantry room. No staff were observed in the kitchen at the time of the inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. The bathroom floor of room 178 had pieces of linoleum peeling away from the floor. This specific observation was cited at the previous inspection on 10/24/2022. 2. The floor around the bed in room 182 had a large area containing a black, sticky substance. Also, the central air unit mounted to the wall under the window was noted to still be missing both knobs to operate the unit. These specific observations were cited at the previous inspection on 10/24/2022. 3. The floor in room 277 was covered in a brown and gray substance next to the residents? beds. This specific observation was cited at the previous inspection on 10/24/2022. Also, the floor of the bathroom contained a dark substance around the base of the toilet and next to the base of the tub. 4. The bathroom tile around and next to the toilet of room 296 was cracked. This specific observation was cited at the previous inspection on 10/24/2022. 5. At 12:05 PM, LI observed red drops of an unknown substance outside of room 281. 6. The bathroom floor in room 169 had a dark substance and yellow stain around the base of the toilet and along the base of the tub. 7. The cover of the central air unit that was mounted to the wall across from room 200 was being secured together by 3M tape. 8. Room 183 contained multiple brown spots on the walls in the bedroom and the bathroom, multiple stains on the floor in the bedroom and in the bathroom around the toilet, multiple brown stains on the inside and outside of the door to the bathroom, and the inside of the vanity in the bathroom was heavily stained. These specific observations were cited at the previous inspection on 10/24/2022. 9. A ceiling tile located outside of rooms 243 and 249 was observed by collaterals 1 and 2 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. These specific observations were cited at the previous inspection on 10/24/2022. 10. Across from room 200 two LIs observed a small brown puddle of water and above there were ceiling tiles that were brown and stained along the edge of the top of the wall. 11. Ceiling stains were observed in the hallway by rooms 199, 202, 224, 252, 275, 280 and 286. 12. Ceiling stains were observed in the common area for Unit 3 by the windows and in the Hallway beside the Unit station. 13. A ceiling stain was observed in the hallway by room 237. The ceiling tile was noted to be bulging and a wet/moist area was noted on the floor under the ceiling tile. 14. Dirt marks and debris were noted in numerous areas on the hallway floor throughout Units 2, 3 and 4. Areas of build-up were observed in edges of the floor against the baseboards/walls. 15. Dirt marks/stains and scuffs were noted in numerous areas on the walls in the hallways of Unit 2, 3 and 4.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-E
Description:	Based on observation, the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition, except that the furnishings and equipment owned by a resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard. EVIDENCE: 1. In the bathroom of room 208, the toilet seat had a large brown and yellow stain. In addition, the toilet bowl had a brown substance inside and on the outside of the bowl. 2. The window screen to the right side of the front entrance to the building had a large hole and numerous scratches.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 units 2 and 4, the signaling devices terminate in the medication rooms/nurses? stations; however, through interview with facility staff it was confirmed that the medication rooms/nurses? stations are not continuously staffed. In addition, there are no individual lights nor audible indicators in the hall outside of residents? rooms. These specific observations were cited at the previous inspection on 10/24/2022. 2. While in unit 2, collateral 1 pushed the signaling device that was mounted on the wall in room 165 at 9:55AM and in room 183 at 9:56AM. At 11:52 AM, collateral 1 noted that the device mounted on the wall in the unit 2 medication room/nurses? station indicated that signaling device was still on for rooms 165 and 183, indicating that the calls had not been answered by staff. 3. The signaling device in room 182 for resident 2 was inoperable during the on-site inspection on 01/05/2023. This was verified by collaterals 1 and 2 as well as staff 1.
Plan of Correction:	Not available online. Contact Inspector for more information.