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: June 27, 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 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:

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/27/2022 8:30am until 3:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on a review of staff records, the facility failed to ensure that direct care staff received the required number of hours of annual training. EVIDENCE: 1. The record for staff person 2, hired on 02/15/2021 has documentation that the employee has only received 1 hour of the required 18 hours of training annually from 02/15/2021 through 02/15/2022.
Plan of Correction:	1. Staff person 2 will attend required trainings for current period 2/15/22-2/15/23 and will attend 6 hours of training by 7/31/22 to begin compliance for current year. 2. Executive Director or designee will ensure that staff members attend required trainings through monthly in-services or online education. 3. Business office Manager, or designee, will be responsible for ensuring staff training is documented and meets annual requirements.
Standard #:	22VAC40-73-210-F
Description:	Based on a review of staff records, the facility failed to ensure that all direct care staff received at least 2 hours of infection control training annually. EVIDENCE: 1. The record for staff person 2, hired on 02/15/2021 did not have documentation that this employee had received any training in infection control between 02/15/2021 through 02/15/2022.
Plan of Correction:	1. Staff person 2 will receive 2 hours of infection control training by 7/31/22. 2. Staff members will receive 2 hours of infection control training by 7/31/22 and ongoing. 3. 3. Business office Manager, or designee, will be responsible for ensuring staff training is documented and meets annual requirements.
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records, the facility failed to ensure that staff received a screening for tuberculosis on or within seven days prior to the first day of work. EVIDENCE: 1. The record for staff person 4, hired on 05/09/2022 has documentation that this employees screening for tuberculosis was not completed until 05/23/2022.
Plan of Correction:	1. Business Office Manager will ensure that all new staff members have a TB screening on or before hire. 2. Executive Director, or designee, will review all new employee files for compliance upon hire.
Standard #:	22VAC40-73-270-1
Description:	Based on a review of staff records, the facility failed to ensure that direct care staff received training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. EVIDENCE: 1. The record for staff person 1, hired on 04/07/2022 and staff person 3, hired on 04/27/2022 do not have documentation that these employees have received any training in residents with aggressive behaviors. The facility houses a mixed population of residents of which some have been assessed with a history of abusive, aggressive or disruptive behavior such as resident 8 as documented of their uniform assessment instrument dated 10/05/2021.
Plan of Correction:	1. Direct Care staff will receive training on aggressive behavior by 8/5/22, upon hire and annually thereafter. 2. Business office Manager, or designee, will be responsible for ensuring staff training is documented and meets annual requirements.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure that the physical examination and report for a person contained all required components. EVIDENCE: 1. The ?Report of Resident Physical Examination? for resident 6, dated 03/03/2022, did not include documentation regarding the resident?s general physical condition including a systems review as is medically indicated.
Plan of Correction:	1. Report of Resident Physical Examination for Resident 6 will be updated by physician to include documentation regarding resident?s general condition. 2. Director of Health & Wellness, or designee, will review all new Residents physical exams prior to admission to ensure compliance. 3. Director of Health & Wellness, or designee, will conduct audit of all Resident physical examinations to ensure compliance.
Standard #:	22VAC40-73-325-B
Description:	Based on resident record review, the facility failed to review and update the fall risk rating for residents who meet the criteria for assisted living care after a fall. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 1, dated 04/19/2022, indicates that the resident is assessed as assisted living level of care. The record for the resident 1 contained documentation on a facility fax form of the resident falling on 01/27/2022 and 02/23/2022. The record for resident 1 did not contain documentation of a fall risk rating being completed for these falls. 2. The UAI for resident 2, dated 03/01/2022 indicates that the resident is assessed as assisted living level of care. The record for the resident 2 contained documentation on a facility fax form of the resident falling on 10/19/2021, 01/02/2022 and 05/23/2022. The record for resident 2 did not contain documentation of a fall risk rating being completed for these falls. 3. The UAI for resident 4, dated 04/04/2022, indicates that the resident is assessed as assisted living level of care. The record for the resident contained a staff note, dated 05/19/2022, with the following information: ?RSD was in group exercise with therapy and lost her balance and fell.? The record for the resident contained documentation that the last fall risk rating completed for the resident was on 04/04/2022. 4. The UAI for resident 6, dated 03/10/2022, indicates that the resident is assessed as assisted living level of care. The record for the resident contained a staff note, dated 04/15/2022, with the following information: ?Resident stated she had a fall.? The record for the resident contained documentation that the last fall risk rating completed for the resident was on 03/10/2022.
Plan of Correction:	1. Fall risk ratings will be completed annually, at change in condition and after each fall. Director of Health & Wellness, or designee, will ensure compliance. 2. Education has been provided to all nursing staff members regarding fall risk rating tool requirement on 6/27/22.
Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to ensure that prior to or at the time of admission to an assisted living facility, all required personal and social information was obtained. EVIDENCE: 1. The resident-personal social data sheet for resident 4, dated 04/04/2022, did not contain documentation of the resident?s strengths and problems. 2. The resident-personal social data sheet for resident 5 was lacking the following requirements: date of admission, current behavioral and social functioning, strengths and problems. 3. The resident ?personal social data sheet for resident 6, dated 03/14/2022, indicated that the resident is a DNR; however, the resident is a Full Code. In addition, the sheet did not contain information on the resident?s current behavioral and social functioning.
Plan of Correction:	1. Personal social data sheets have been updated for Residents 4, 5 & 6. 2. Executive Director or designee will ensure personal social data sheets are completed correctly upon admission. 3. Director of Health & Wellness or designee will an conduct audit of personal social data sheets on all current Resident files to ensure compliance.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review, the facility failed to ensure that private pay uniform assessment instruments (UAIs) were completed as required. EVIDENCE: 1. The UAI dated 03/01/2022 in the record for resident 2 is incomplete as it has that the resident is disoriented to some spheres all the time but does not have documentation of which spheres are affected. 2. The UAI dated 10/05/2021 in the record for resident 8 is incomplete as it has that the residents behavior pattern is abusive, aggressive, disruptive weekly or more but does not have documentation of the residents specific behaviors.
Plan of Correction:	1. UAI?s for Resident 2 and 8 have been updated by Director of Health & Wellness. 2. Director of Health & Wellness or designee will conduct audit of all current Resident UAI?s to ensure compliance. 3. Director of Health & Wellness or designee will review all new Resident UAI?s to ensure compliance.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to update the individualized service plan (ISP) as needed for a significant change of a resident?s condition. EVIDENCE: 1. The record for resident 5 contained a durable do not resuscitate order (DNR), signed and dated 05/31/2022; however, the resident?s ISP, dated 05/27/2022, indicated that the resident is a Full Code and that the resident will receive CPR in the event of a cardiac and/or respiratory arrest. 2. The record for resident 1 has a physician order dated 02/23/2022 for knee immobilizer between knees while the resident is in bed. The ISP dated 04/18/2022 in the record for resident 1 does not reflect this identified need. 3. The uniform assessment instrument dated 03/01/2022 in the record for resident 2 has documentation that the resident requires physical assistance with transfers. The record also has a physician order dated 07/29/2021 to crush resident 2?s medications. The ISP dated 03/01/2022 for resident 2 does not reflect these identified needs.
Plan of Correction:	1. ISP?s for Residents 5, 1 and 2 have been updated. 2. Director of Health & Wellness or designee will conduct audit of all current Resident ISP?s to ensure compliance.
Standard #:	22VAC40-73-550-G
Description:	Based on resident record review, the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities were reviewed annually with residents and staff. EVIDENCE: 1. The record for resident 7, admitted on 06/10/2021, did not include documentation that a review of the rights and responsibilities of residents in assisted living facilities had been completed with the resident since 06/10/2021. 2. The record for resident 1 has documentation that the last annual review of resident rights and responsibilities was completed on 04/14/2021. 3. The record for resident 8 has documentation that the last annual review of resident rights and responsibilities was completed on 12/03/2020. 4. The record for staff person 2 has documentation that the last annual review of resident rights and responsibilities was completed on 12/18/2020.
Plan of Correction:	1. Residents 7, 1 & 8 have received annual review of Resident Rights. 2. Staff member 2 has received review of Resident Rights. 3. Residents & Staff member will receive review of Resident Rights upon admission/hire. 4. Executive Director or designee will ensure compliance.
Standard #:	22VAC40-73-580-B
Description:	Based on observation during on-site inspection and staff interviews, the facility failed to have a written agreement signed and dated by both the resident and the licensee or administrator when the facility offers routine or regular room service when residents have the option of having meals in their rooms. EVIDENCE: 1. During on-site inspection on 06/27/2022, one licensing inspector observed food being delivered to resident 9?s room during the noon-time meal. During interview with staff persons 4 and 5, both staff revealed that the resident does eat her meals in her room and that the facility does not have a written agreement signed and dated by both the resident and the licensee or administrator regarding the resident eating her meals in her room.
Plan of Correction:	1. Executive Director or designee will ensure that Residents who choose to have meals in their rooms will sign a room service agreement upon admission or change in meal delivery status. 2. Resident 9 has signed a room service agreement.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 6 contained a physician?s order, dated 03/25/2022, for the following: ?Humalog 100U/ML inject sub-q per sliding scale before meals for diabetes mellitus: 0-199=0 units (U); 200-250=2U; 251-300=4U; 301-350=6U; 351-400=8U: Above 400=10U and recheck BS (blood sugar) in 1 hour. If BS remains above 400, call MD (medical doctor)?. 2. The June 2022 medication administration record (MAR) for resident 6 indicated that the resident?s blood sugar was 310 at 11:00AM on 06/02/2022 and 6 units of Humalog should have been administered according to the aforementioned physician?s order; however, the MAR indicated that 4 units of Humalog was administered to the resident. 3. The June 2022 MAR for resident 6 indicated that the resident?s blood sugar was 518 at 5:00PM on 06/06/2022; however, there was no documentation that the resident?s blood sugar had been retaken at 6:00PM by the appropriate facility staff as indicated by the aforementioned physician?s order dated 03/25/2022.
Plan of Correction:	1. Staff member responsible listed violation has re-educated and disciplinary coaching regarding following physician order and documentation of med administration. 2. Med refresher class for all med administration staff has been scheduled for 7/8/22. 3. Director of Health & Wellness or designee will conduct Medication Administration Record audits to ensure compliance.
Standard #:	22VAC40-73-860-D
Description:	Based on observation during a tour of the physical plant, the facility failed to ensure all operable windows (i.e., a window that may be opened) were effectively screened. EVIDENCE: 1. During on-site inspection on 06/27/2022, the following windows, located by rooms 115, 118 and 130 at the end of the hallways on the first floor, were operable and did not contain a screen.
Plan of Correction:	1. Director of Facility ops or designee will replace screens in rooms 115, 118 and 130 and ensure operational status. 2. Director of Facility Ops or designee will conduct an audit of all Resident rooms to ensure window compliance.
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the physical plant, the facility failed to ensure all cleaning supplies and other hazardous materials were in a locked area. EVIDENCE: 1. At approximately 9:29 AM on the day of inspection, the LI noted an unlocked door on the first floor labeled ?Employees Only?. The door led into a hallway area and a closet with a propped open door was observed. The closet contained the following cleaning products: Super Suds Dish Detergent, Dawn Dish Detergent, Spray Nine Heavy Duty cleaner, Sani-Tyze, Ecolab Lime-A-Way and Windex. This was also observed by staff persons 4 and 6.
Plan of Correction:	1. Door to cleaning closet has been locked. 2. Sign has been placed on door notifying all staff that door must be locked. 3. All staff have been educated on 6/28/22 regarding requirement. 4. Dining Director & Maintenance Director will monitor door frequently to ensure door is secure.
Standard #:	22VAC40-73-940-A
Description:	Based on a review of facility documentation, the facility failed to ensure compliance with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. EVIDENCE: 1. The most recent Fire Marshall inspections available for review on the day of inspection was dated 11/23/2020.
Plan of Correction:	1. Director of Facility Ops or designee will contact Fire Marshall to schedule inspection.
Standard #:	22VAC40-73-970-E
Description:	Based on a review of facility documentation , the facility failed to ensure that all required information was included on the facility fire drill logs. EVIDENCE: 1. The facility fire drill logs for April, May and June 2022 did not include the identity of the person conducting the drill, the method used for notification of the drill; the number of staff participating; the number of residents participating; any special conditions simulated; the time it took to complete the drill; weather conditions; and problems encountered, if any.
Plan of Correction:	1. Director of Facility Ops has been educated regarding fire drill procedures. 2. Executive Director has provided Director of Facility Ops with state required form to document fire drills accordingly. 3. Executive Director will conduct routine audits of fire drill documentation to ensure compliance.