VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Restin South
6347 Crowell Gap Road
Roanoke, VA 24014
(540) 774-9255

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: Feb. 19, 2020

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 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 SANCTIONS.

Comments:

The LI for Restin South conducted an unannounced renewal study at the facility on 2/19/2020 from 10am until 3pm and noted 10 residents to e in care. Resident and staff records as well as other forms of facility documentation were reviewed and interviews were conducted with residents and staff. A tour of the facility physical plant was conducted and the mid day medication pass and mid day meal were observed. Please respond back to your LI within 10 days of receipt of this notice with your plan of correct. If you have any questions please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records, the facility failed to ensure that all staff completed a screening for tuberculosis annually. EVIDENCE: 1. The record for staff person 2, hired 12/20/2016 has documentation that the last screening for tuberculosis was a chest x-ray completed 9/8/2018. 2. The record for staff person 3, hired on 7/1/2012 has documentation that the last screening for tuberculosis was completed in 2018.
Plan of Correction:	Staff person 2 has set an appointment and will have it by 3/3/20. Staff 3 retrieved her record and is on file. Administrator will ensure all staff records are kept up to date and remind as necessary.
Standard #:	22VAC40-73-310-B
Description:	Based on a review of resident records, the facility failed to ensure that a documented interview was completed prior to admission to ensure determination could be made that the facility could meet a potential residents needs. EVIDENCE: 1. The records 2, admitted on 1/27/2020 and resident 4, admitted on 2/22/2019 did not contain documentation of an interview being completed prior to their admission.
Plan of Correction:	Administrator will document that a interview was done prior to admission for determination. This will be signed by staff.
Standard #:	22VAC40-73-350-B
Description:	Based on a review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days. EVIDENCE: 1. The record for resident 2, admitted on 1/27/2020, did not contain documentation that a sex offender screening was completed prior to the residents admission.
Plan of Correction:	This was accomplished on 2/19/20 and administrator will ascertain the sex offender status before any new admissions.
Standard #:	22VAC40-73-550-F
Description:	Based on a review of facility posted items, the facility failed to update their resident rights posting per regulation changes that were effective in February 2018. EVIDENCE: 1. The resident rights posting currently in the facility was an old form from 2007. The posting was not in 14 point type and did not contain accurate contact information the the licensing administrator.
Plan of Correction:	The new resident rights posting was printed and put on bulletin board.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observations made of the facility physical plant, the facility failed to store medications in a locked area. EVIDENCE: 1. Two containers of Triamcinolone Acetonide 0.1% cream was noted sitting out in an unlocked area in room 4. 2. A bottle of Redness Relief eye drops were noted sitting out in an unlocked area in room 5. 3. The first aid cabinet was noted to be unlocked on the day of inspection and contained a bottle of Hydrogen Peroxide, a bottle of Swan Iodine, a container of Equate Vaporizing Rub, a tube of First Aid Antibiotic and a tube of Bacitracin Zinc ointment.
Plan of Correction:	All medications were secured or destroyed. The first aid kit and supplies were moved from the cabinet to a locked room. Administrator will oversee these corrections to maintain them.
Standard #:	22VAC40-73-660-B
Description:	Based on observations made of the facility physical plan and review of resident records, the facility failed to ensure that residents who administer their own medications store medications in an out of sight place in their rooms. EVIDENCE: 1. The record for resident 7 has a physician order for Terbinafine Hydrochloride 1% cream ,apply daily as needed and that the resident may self apply. The medication was noted to be siting out in a green basket in the residents room on the day of inspection.
Plan of Correction:	All medications were put out of sight and safe from others from now on.Medication will be kept in med room until needed by resident. Staff will oversee this ongoing.
Standard #:	22VAC40-73-680-E
Description:	Based on a review of resident records, the facility failed to ensure that medical procedures ordered by a physician were documented as required. EVIDENCE: 1. The February 2020 medication administration record (MAR) for resident 8 has a physician order for Metoprolol 25mg, 1 and a half tab daily but to hold the medication if the residents pulse is less than 60. The is no documentation of a pulse being completed on 2/4/2020.
Plan of Correction:	This was oversight on part of administrator. BP and pulse are checked every am. I didn't write it in.
Standard #:	22VAC40-73-680-I
Description:	Based on a review of resident records, the facility failed to ensure that all required information was documented on medication administration records. EVIDENCE: 1. The February 2020 MAR for resident 4 has staff initials 3 times a day from 2/1/2020 through 2/4/2020 for the PRN medication Diphenhydramine 25mg. The MAR does not have documentation of the times that the medication was given, the reason for the administration of the mediation of the effectiveness.
Plan of Correction:	Resident 4 was having recurrent issues with his skin and at one point the medication was scheduled. This was a major oversight on the part of the administrator and staff and I will ensure clarity from now on and communicate orders as directed for PRN's also.