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: July 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.

Comments:

A renewal inspection was initiated on 7/12/2021 and concluded on 7/15/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 63. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 4 resident records, 4 staff records, healthcare and special diet oversight, Fire and Health Department inspections, fire drill logs, activities calendar and staff schedules, etc. submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 7/15/2021. An exit interview was conducted with the Administrator and Director of Nursing on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-660-A-7
Description:	Based on observations made of the facility medication carts during an on-site inspection conducted on 7/15/2021, the facility failed to ensure that dedicated medical equipment was appropriately labeled. EVIDENCE: 1. The glucometer on the medication cart for resident 3 was noted to be in a labeled bag for the resident but the glucometer itself was not labeled with the residents name.
Plan of Correction:	1. The bag the glucometer was in was labeled, although the glucometer itself was not. The glucometer was immediately labeled with resident 3?s name on the day of the inspection. 2. The Director of Health & Wellness or designee will continue to check glucometers for the appropriate labeling during monthly medication cart audits. 3. The Director of Health & Wellness or designee will ensure compliance with the standard.
Standard #:	22VAC40-73-680-M
Description:	Based on observations of the facility medication carts made during an on-site inspection conducted on 7/15/2021, the facility failed to ensure medications for PRN use were properly stored at the facility. EVIDENCE: 1. The record for resident 2 has a physician order for Acetaminophen 500mg, 2 tablets every 6 hours as needed for pain. This PRN was not available on the medication cart at the time of this inspection.
Plan of Correction:	1. The PRN medication was ordered and available in the medication cart the day following the inspection. 2. The Director of Health & Wellness or designee will continue to ensure the availability of PRN medications during monthly medication cart audits. 3. The Director of Health & Wellness or designee will ensure compliance with the standard.
Standard #:	22VAC40-73-700-1
Description:	Based on a review of resident records, the facility failed to insure tht oxygen orders contained all required iformation. EVIDENCE: 1. The oxygen order in the records for residents 2 and 4 did not contain the source of the oxygen or the times for when the oxygen should be worn.
Plan of Correction:	1. The oxygen orders for residents 2 and 4 were received as a portion of hospital discharge orders. The orders did not contain the source of the oxygen or the times for when the oxygen should be worn. The oxygen orders for residents 2 and 4 have been clarified and updated in the medical record to include all required information. An audit of all other resident oxygen orders was completed to ensure that the orders contained required information. 2. The nursing staff have been re-educated that all oxygen orders must include the following: the oxygen source, the delivery device, and the flow rate deemed therapeutic for the resident. 3. The Director of Health & Wellness or designee will ensure compliance with the standard.
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during an on-site inspection conducted on 7/15/2021, the facility failed to ensure the interior of the building was kept clean and good repair. EVIDENCE: 1. During a tour of the facility physical plant conducted with the presence of the administrator, the carpet in the hallways on the 1st, 2nd and 3rd were noted to be soiled, stained and rolling up/raveling in numerous areas on all 3 floors.
Plan of Correction:	1. The carpet in the hallways on all 3 floors were last extracted on 7/12/2021. Estimates will be obtained and repairs where the carpet is rolling up and raveling will occur as soon as possible. 2. The Director of Facility Operations and/or Facility Operations Assistant will obtain estimates for the carpet to be replaced on all 3 floors. The carpet will be replaced in phases as follows: the 3rd floor will be replaced within the next 3 months, the 1st within 6 months, and the 2nd within 9 months. The Director of Facility Operations or designee will ensure that the carpet on all 3 floors continues to be extracted on a bi-weekly basis until the replacement occurs. 3. The Executive Director or designee will ensure compliance with the standard.
Standard #:	22VAC40-73-870-B
Description:	Based on observations made during an on-site inspection conducted on 7/15/2021, the facility failed to ensure that the building was free from foul dors. EVIDENCE: 1. The 1st floor hallway outside of room 105 and inside room 105 was noted to have a very strong cat urine odor on the day of inspection. It was noted that a cat is currently living in room 105.
Plan of Correction:	1. The housekeeper assigned to apartment 105 replaces the litter in the litter box on a weekly basis and the apartment is deep cleaned on a monthly basis. After further investigation, it has been determined that the cat urine odor is being caused by the cat spraying. The Executive Director and Director of Health & Wellness will assess the residents continued ability to care for the cat and respond accordingly. 2. The housekeeping staff and/or Executive Director will continue to monitor and assess resident ability to care for animals within the Community. 3. The Executive Director or designee will ensure compliance with the standard.