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: April 19, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 04/29/2022 and 06/27/2022 A self-reported incident was received by VDSS Division of Licensing on 04/19/2022 regarding allegations in the area of resident care and related services. Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. 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 #:	22VAC40-73-470-F
Description:	Based on a review of resident records, the facility failed to ensure that medical attention from a licensed healthcare professional was secured immediately when a resident suffered a serious accident, injury, illness or medical condition or reason to suspect that such has occurred. EVIDENCE: 1. A facility self reported incident was received by the LI on 04/19/2022 in regards to resident 1 falling on 04/17/2022 at 10:10pm. 2. Charting Notes in the record for resident 1 has documentation that at 10:10pm on 04/17/2022, resident 1 rang her call bell for staff assistance. Staff arrived to resident 1?s room and found resident 1 lying on the floor on her right side. Charting notes express that resident 1 indicated that she lost her balance while exiting her kitchen and had no complaints of pain or discomfort at this time. Charting notes explain that staff assisted resident 1 up off the floor and that resident 1 ambulated back to her bedroom. 3. Documentation in charting notes for resident 1 has that resident 1 was complaining of some discomfort with her right hip during rounds that were made at 2:00am on 04/18/2022. There is no documentation that resident 1 received medical attention from a licensed healthcare professional until 10:22am on 04/18/2022 when staff person 3, who is a licensed health care professional documented in charting notes on resident 1. 4. Charting notes in the record for resident 1 has documentation at 5:46pm on 04/18/2022 that resident 1?s family was in to see the resident and called 911 due to complaints of right hip pain. A hospital discharge summary dated 04/22/2022 has documentation that resident 1 was diagnosed with a comminuted fracture right greater trochanter requiring non-operative management.
Plan of Correction:	LPN on duty the day of the incident states that when she went in to administer medications, resident complained of pain on right side. LPN offered ER for assessment; Resident declined. LPN then followed Resident to the bathroom, LPN states that ROM was normal, and that Resident walked without difficulty to and from bathroom. Upon returning to her bed, Resident then refused any assistance. LPN notified Residents son that she complained of pain, who stated ?I will be there later to check on her, this is Mom, she is spoiled?. 1. Nursing staff have been re-educated regarding post fall protocol to include notifying the LPN on call and notifying the hospice provider at the time of fall, if applicable. 2. Post- fall protocol has been attached to fall risk assessment for charge staff person review and completion post fall. 3. A licensed healthcare provider will be on call 24/7 and be available to provide immediate guidance to nursing staff regarding any incidents.