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: Dec. 18, 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

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: 12/18/2023 from 08:30 AM until 03:30 PM 12/19/2023 from 09:00 AM until 01:00 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 #:	22VAC40-73-640-A
Description:	Based on record review and staff interview, the facility failed to implement a portion of its medication management plan, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes. EVIDENCE: 1. The facility?s medication management plan, provided during the inspection on 12/19/2023, indicates the following: ?Our medication narcotic count will be done and signed at shift change or at the time they are counted?. 2. The December 2023 CONTROLLED DRUGS ? COUNT RECORD form for cart A and cart C in unit 2 did not contain signatures for oncoming and off-going staff at each shift change on December 14, 15, and 16. 3. The INDIVIDUAL RESIDENT CONTROLLED SUBSTANCE RECORD for resident 11?s AM Clonazepam 0.5 MG tab indicated that there should be 11 pills on the cart; however, the physical count of pills on the cart totaled 9. 4. The INDIVIDUAL RESIDENT CONTROLLED SUBSTANCE RECORD for resident 12?s NOON Methadone HCL 5 MG tab indicated that there should be 25 pills on the cart; however, the physical count of pills on the cart totaled 24. 5. An interview with staff 1 and staff 2 could not clarify the cause of the discrepancy between the records and physical counts for resident 11?s medication and resident 12?s medication.
Plan of Correction:	North Roanoke Assisted Living will comply with Standard 640-A. North Roanoke Assisted Living will continue to abide with standard as it relates. The facility medication management plan is suitable and the facility will comply with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. The cited violation was corrected on site and moving forward the narcotic count will be recorded as the narcotic is administered. NRAL Nursing personnel and Registered Aide will pay close attention to narcotic count and documentation to prevent any future errors. 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 and staff interview, 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. While performing the physical plant walk-through on 12/18/2023, LI observed that the flooring on the interior ramps between unit 2 and unit 4 was chipped in several areas. 2. An interview with staff 6 and staff 7 confirmed that the interior ramps are in unit 3 and both acknowledged the condition of the chipped flooring in that area.
Plan of Correction:	North Roanoke Assisted Living will comply with Standard 870-A. North Roanoke Assisted Living will continue to abide by the standard it relates to the facility ensuring that the interior and exterior of all buildings shall be 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 address and maintain the interior and exterior of all buildings. The flooring indicated is on Unit 3, is an unoccupied unit with no residents residing in this area and is utilized as a breezeway for the residents to travel through the facility when inclement weather. North Roanoke Assisted Living will address the broken tiles and repair as needed moving forward. 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.