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 20, 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 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: 07/20/2023 8:40am until 2:30pm 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: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 12 Number of staff records reviewed: 7 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 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 #:	22VAC40-73-100-C-1
Description:	Based on observations of the facility medication carts, the facility failed to follow their policy and procedures for infection control in regards to assisted blood glucose monitoring. EVIDENCE: 1. The facility infection control policy has documentation that ?Blood Glucose Monitors should never be used for more than one person. Should be cleaned and disinfected after every use?. The facility medication management plan has documentation that ?All glucometers and cases are to be labeled with residents name?. 2. A glucometer bag with a glucometer was noted in the second-floor odd medication cart. No name was observed on the bag or meter as of the day of inspection. Room # 233 was noted to be documented on the test strip located in the bag.
Plan of Correction:	Glucometer was labeled at time of inspection. Cart audits were completed on 7/20/2023 and all glucometers were labeled as well as the container. RMA?s will check each glucometer before each use to ensure that they are labeled. RCC or Designee will conduct bi-weekly medication cart audits to ensure that glucometers are labeled and are in individual containers which are labeled.
Standard #:	22VAC40-73-200-B
Description:	Based on record review, the facility failed to ensure that direct care staff, who are responsible for caring for residents with special health care needs, shall only provide services within the scope of their practice and training. EVIDENCE: 1. The July 2023 medication administration record (MAR) record for resident 10 has documentation of a physician order for a Freestyle Libre 2 Sensor to ?Check blood sugar. Change every 2 weeks?. The July 2023 MAR has documentation of the initials of Staff person 7, who is a registered medication aide (RMA), on 07/07/2023 for changing the Freestyle Libre 2 Sensor. The site placed was documented to be resident 10?s right anterior thigh (RAT). This procedure is not within the scope of practice for an RMA as training for the changing/care of a Freestyle Libre 2 Sensor is not included in the medication aide curriculum.
Plan of Correction:	Education was provided by RN to all RMA?s on 7/21/2023. RN or LPN will change freestyle Libre sensors as ordered by MD and document on MAR.
Standard #:	22VAC40-73-250-D
Description:	Based on review of staff records, the facility failed to ensure that staff received a screening for tuberculosis annually. EVIDENCE: 1. The record for staff persons 2 and 3 both hired on 02/15/2021, has documentation that the last annual screening for tuberculosis was completed on 06/07/2022.
Plan of Correction:	100% audit will be completed on all staff members by 8/18/2023. TB screenings will be current and up to date. Screening will be performed by RN or LPN upon hire and annually thereafter.
Standard #:	22VAC40-73-270-1
Description:	Based on review of staff records, the facility failed to ensure that aggressive behavior for direct care staff included all required components. EVIDENCE: 1. Documentation of aggressive behavior training in the records for staff 2 and 3 has that the training was an on-line/video-based training. The training does not have documentation of the qualified health professional who completed the training or of any demonstration and practical experience in self-protection and in the prevention and de-escalation of aggressive behavior.
Plan of Correction:	Aggressive Behavior training will be held on 8/18/2023 for all staff and will include all components of the training including the demonstration and practical experience. This training will be completed by the RN upon hire and annually and will include all components of the training.
Standard #:	22VAC40-73-440-B
Description:	Based on resident record review, the facility failed to ensure a completed private pay uniform assessment instrument (UAI) was signed by the administrator or the administrator?s designated representative. EVIDENCE: 1. The UAI in the record for resident 6, with a reassessment date of 06/25/2023, does not include the signature of the assessor, the administrator or designee?s signature on page 2.
Plan of Correction:	100% audit of all UAI?s will be completed by 8/18/2023 on all current Residents. DHW or Designee will audit all UAI?s upon admission, at change of condition and annually to ensure that the signatures are correct.
Standard #:	22VAC40-73-450-D
Description:	Based on resident record review, the facility failed to ensure that when hospice care is provided to a resident, the agreed upon coordinated plan of care and the services provided by each were included on residents individualized service plans (ISP). EVIDENCE: 1. The ISP dated 10/04/2022 in the record for resident 5 has documentation of an identified need for Hospice care dated 10/04/2022. The ISP does not identify/include documentation of the coordinated plan of care or any details of services that are being provided by the Hospice provider.
Plan of Correction:	All current Residents that receive Hospice services will have their ISPs updated by 8/18/2023 and will include each disciplinary, care provided, and outcome according to the plan of care by Hospice. Any new Hospice orders will be updated by the DHW or designee at the time of the order.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and staff interview, the facility failed to ensure that all required information was included when individualized service plans (ISPs) are reviewed and updated. EVIDENCE: 1. The ISP for resident 4, dated 01/13/2023, indicates that the resident has a wander guard located on her right ankle due to disorientation of place; however, the record for resident 4 contains a signed physician?s order, dated 04/24/2023, that the physician discontinued the resident?s wander guard. Interview with staff 1 confirmed on date of inspection that resident 4 no longer wears a wander guard and this should no longer be included on the resident?s ISP. 2. The uniform assessment instrument (UAI) dated 09/20/2022 in the record for resident 5 has documentation that the resident is disoriented to some spheres some of the time with date being listed as the sphere affected. The ISP dated 10/4/2022 in the record for resident 5 is inconsistent as it has documentation that resident 5 is orientated to all spheres. When interviewed by two LIs, staff 1 indicated that the UAI was correct, and that it was an error on the completed ISP.
Plan of Correction:	ISP was updated at the time of the inspection; Any future Residents that require wander guard for safety will be updated on the ISP at the time the order is written and/or discontinued. ISP?s will be audited monthly by the DHW or designee to ensure the ISP is updated.
Standard #:	22VAC40-73-680-G
Description:	Based on observations of the facility medication carts, the facility failed to ensure that all over the counter medications were labeled with a residents name. EVIDENCE: 1. The second-floor odd medication cart contained a bottle of Tylenol PM in the second drawer that did not have documentation of the residents name in which the medication is for.
Plan of Correction:	100% Audit was completed on 7/21/2023, 7/24/2023, and 7/25/2023. All unlabeled OTC medications have been labeled with the Residents full name. All new OTC medications that are not labeled will be labeled immediately before being placed on medication cart. Bi-weekly audits will be performed by the RCC or Designee to ensure compliance.
Standard #:	22VAC40-73-950-E
Description:	Based on review od facility documentation, the facility failed to ensure that a 6-month review of emergency preparedness policies and procedures was completed with all residents. EVIDENCE: 1. Documentation of a 6-month review of the facility emergency preparedness and response plan with all residents was not available for review on the day of inspection.
Plan of Correction:	ED will review facility emergency preparedness and response with all residents by 8/15/2023 during Resident Counsel/Communication Meeting and every 6 months thereafter. ED will meet with any resident who does not attend meeting by 8/31/2023 to review on 1:1 basis.
Standard #:	22VAC40-73-980-H
Description:	Based on observations of the facility emergency food and water supply, the failed to ensure an on-site 48-hour supply of emergency water. EVIDENCE: 1. The emergency water stored in a storage closet located on the facility first floor was noted to have an expiration date of 03/31/2023 as of the day of inspection.
Plan of Correction:	All emergency water in storage closet with expired dates was pulled and disposed of on date of inspection. Director of Culinary Services purchased emergency water same day. DCS will audit emergency water closet monthly to ensure water is not expired.