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: March 20, 2024 and April 4, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Dates of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/20/2024 08:00am to 11:20am, 4/4/2024 09:35am to 11:40am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 3/18/2024 regarding allegations in the area of: Staffing and Supervision and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 88 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 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 allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards 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 A Marie Swink, Licensing Inspector at 276-635-6575 or by email at angela.swink@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-280-B
Complaint related:	Yes
Description:	Based on document review and staff interview, the facility failed to implement their written plan that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care. EVIDENCE: 1. The facility?s written plan, provided by staff person 2, that specifics the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care, showed that the facility will have 4 - 6 staff providing direct care from 8AM - 8PM daily and 3 ? 5 staff providing direct care from 8PM ? 8PM daily. 2. Staff schedule, provided by staff person 2, has documentation for approximately 6 days from 3/11/2024 through 3/17/2024 that the facility did not have the number of direct care staff working at all times that the written plan stated is needed. 3.During an interview on 4/4/2024 with one licensing inspector and staff person 2, staff person 2 disclosed that 8 non-ambulatory residents reside in the facility and the facility has a mixed population. Staff person 2 confirmed the staff schedule provided accurately represented the number of staff providing direct care each day.
Plan of Correction:	Facility had a hiring blitz 4/1/2024-4/5/2024, have increased 4/15/2024 clinical staff to 22 employees. DHW will oversee the schedule and utilize OnShift scheduling program. The schedule will be staffed per disclosure statement: 4-6 providing direct care from 8AM-8PM, 3-5 providing. direct care from 8P-8A. If there is a call out, we have an on-call system consisting of DHW and (2) RCC?s to cover call outs. DHW will review staffing needs daily and make adjustments as necessary.
Standard #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	Based on resident record review and staff interview, the facility failed to ensure the comprehensive individualized service plan was completed within 30 days after admission. EVIDENCE: 1. During the on-site inspection on 3/20/2024, the record for resident 1, admission date 7/18/2023, did not contain a comprehensive individualized service plan. 2.During an interview on 3/20/2024 with one licensing inspector and staff person 1, staff person 1 confirmed that the record was current.
Plan of Correction:	Comprehensive ISP will be completed by DHW, reviewed and explained to resident and signature obtained. A copy will be placed in resident file and given to resident