VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Park at Oak Grove
4920 Woodmar Drive
Roanoke, VA 24018
(540) 989-9501

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: May 12, 2021

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.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 5/12/2021 and concluded on 5/12/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 59. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, fire and health inspections, staff schedule, health care and special diet oversights, facility medication management plan, facility infection control policy and fire drill logs submitted by the facility to ensure documentation was complete. 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 #:	22VAC40-73-440-A
Description:	Based on a review of resident records, the facility failed to ensure that private pay uniform assessment instruments (UAI) were updated when there was a significant change in a residents condition. EVIDENCE: 1. The record for resident 3 has documentation in charting notes dated 4/19/2021 that a wander guard was placed on resident 3 due to the resident having wandering/exit seeking behaviors. The private pay UAI dated 3/1/2021 was not updated to reflect the significant change in resident 3's behavior as it has documentation that resident 3's behavior is appropriate.
Plan of Correction:	1. The private pay UAI for resident 3 will be updated to reflect the significant change in resident 3?s behavior. 2. The Director of Health and Wellness will continue to monitor the accuracy of the UAI?s during quarterly healthcare oversight reviews and random chart audits. 3. The Executive Director or designee will ensure compliance with the standard.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that all identified needs were addressed on residents individualized service plans (ISPs). EVIDENCE: 1. The comprehensive ISP dated 9/30/2020 in the record for resident 1 has documentation of the resident being a risk for falls. The record for resident 1 has documentation in charting notes of the resident falling on 3/16/2021 and 3/23/2021. In a phone interview with staff person 5 on 5/12/2021 it was expressed that interventions for falls would be documented on residents ISP's. The ISP for resident 1 does not address any additional interventions put in place for fall prevention since these falls occurred. 2. The history and physical dated 4/5/2021 in the record for resident 2 has documentation that the resident is allergic to adhesives and hand sanitizer. The comprehensive ISP dated 4/7/2021 does not address these identified needs. 3. The record for resident 3 has documentation in charting notes dated 4/19/2021 that a wander guard was placed on resident 3 due to the resident having wandering/exit seeking behaviors. The comprehensive ISP dated 4/19/2021 was not updated to address the identified need for wandering behaviors as it has documentation that resident 3's behavior is appropriate. 4. The comprehensive ISP revised on 4/19/2021 in the record for resident 3 has documentation of the resident being identified as a risk for falls on 3/1/2021. The record for resident 3 has documentation in charting notes of the resident falling on 3/1/2021, 3/12/2021, 4/14/2021, 4/23/2021 and 4/26/2021. In a phone interview with staff person 5 on 5/12/2021 it was expressed that interventions for falls would be documented on residents ISP's. The ISP for resident 3 does not address any additional interventions put in place for fall prevention since these falls occurred.
Plan of Correction:	1. The comprehensive ISP?s for resident 1, 2, and 3 will be updated to reflect all identified needs. 2. The Director of Health and Wellness will continue to monitor the accuracy of the ISP?s during quarterly healthcare oversight reviews and random chart audits. 3. The Executive Director or designee will ensure compliance with the standard.