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. 10, 2021

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 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 2/10/2021 and concluded on 2/16/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 9. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 2 resident records, 2 staff records, facility health care oversight, fire drill logs, Fire and Health Department inspections, dietician oversight, infection control and medication management policies submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-100-A
Description:	Based on a review of facility policy and procedures, the facility failed to develop, in writing, and implement an infection control program addressing the surveillance, prevention, and control of disease and infection that is consistent with the federal Centers for Disease Control and Prevention (CDC) guidelines and the federal Occupational Safety and Health Administration (OSHA) bloodborne pathogens regulations. EVIDENCE: 1. The facility infection control program provided to the LI for review does not contain all required elements of this regulation as it lacks information on the use of standard precautions, the use of personal protective equipment, means to ensure hand hygiene, use of safe injection practices and other procedures where the potential for exposure to blood or body fluids exists, Blood glucose monitoring practices that are consistent with CDC recommendations including when assisted blood glucose monitoring is required fingerstick devices shall not be used for more than one person and the handling, storing, processing, and transporting of medical waste in accordance with applicable regulations.
Plan of Correction:	The Administrator will review the infection control policy to include all required items.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The uniform assessment instrument (UAI) dated 12/9/2020 in the record for resident 2 has documentation that the resident requires mechanical assistance with bathing and physical assistance with eating/feeding. The comprehensive ISP dated 1/28/2021 is inconsistent as it does not have any documentation to address these identified needs.
Plan of Correction:	The Administrator will contact the UAI assessor to get clarification and will update the ISP accordingly.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of resident records, the facility failed to ensure that all required documentation was completed for annual review of resident rights. EVIDENCE: 1. The records for resident 1 and 2 have the residents signatures for completion of an annual review of resident rights and responsibilities with each resident but the date of the completion of the review is not included on the signature pages.
Plan of Correction:	The Administrator will ensure that annual review of resident rights are dated appropriately.
Standard #:	22VAC40-73-640-A
Description:	Based on a review of facility policy and procedures, the facility failed to keep their medication management plan current. EVIDENCE: 1. The facility medication management plan provided to the LI for review does not contain all requirements of this standard as it is lacking the facility standard dosing schedule, methods to prevent the use of outdated, damaged, or contaminated medications; methods to ensure that each resident's prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages, methods for monitoring medication administration and the effective use of the MARs for documentation, Methods to ensure that MARs are maintained as part of the resident's record, methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes, methods to ensure that staff who are responsible for administering medications are adequately supervised, including periodic direct observation of medication administration, methods to ensure that residents do not receive medications or dietary supplements to which they have known allergies and Procedures for internal monitoring of the facility's conformance to the medication management plan.
Plan of Correction:	The Administrator will review the facility medication management plan to include all required items.
Standard #:	22VAC40-73-690-A
Description:	Based on a review of resident records, the facility failed to ensure completion of an annual review of residents medications. EVIDENCE: 1. The record for residents 1 and 2 did not contain documentation that an annual review of the residents medications was completed.
Plan of Correction:	The Administrator will ensure that a medication review is completed for these residents and annually for all residents.