VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Evergreen Assisted Living Community
1437 Peter's Creek Road, NW
Roanoke, VA 24017
(540) 526-8022

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: June 11, 2019

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 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 SANCTIONS.

Technical Assistance:

The facility received technical assistance on the following: 290B - post the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public; 390C - original agreement/acknowledgment shall be updated whenever there are changes to any of the policies or information referenced or identified in the agreement/acknowledgment and dated and signed by the licensee or administrator and the resident or his legal representative; & 550G - rights and responsibilities of residents in assisted living facilities shall be reviewed annually with staff person to include written acknowledgment date of the review and shall be filed in the resident's or staff person's record.

Comments:

The renewal inspection resulted in 6 violations. At 7:07 am, the inspection commenced and concluded at 10:24 am. The census was 4 residents. During the inspection the following was reviewed: physical plant walk through; 4 residents and 3 staff records review; medication pass observation; interviews and other reviews. After completing the inspection, the facility staff and LI discussed the violations, possible corrective actions and had an open discussion. Please contact your license inspector, if you have any further concerns. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain the following: 1) steps to correct the noncompliance with the standard(s); 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Please contact your license inspector, if you have any further concerns 540 309 5982.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on resident record review and staff interview, the facility failed to ensure the physical examination report contained all the required information. Evidence: 1. Resident 1's 3/21/19 physical examination report did not state self medication status. Staff 2 confirmed the facility did not seek clarification from the physician.
Plan of Correction:	The Administrator shall ensure that current model form for report of physician examination as approved by the Department of social services licensing is used for all documentation of report of physical examination for all residents.
Standard #:	22VAC40-73-325-B
Description:	Based on resident record review and staff interview, the facility failed to ensure all residents receive an annual fall risk rating. Evidence: 1. Assisted living resident 3 did not have did not have a fall risk rating in the record. Staff 2 was unable to locate documentation to demonstrate compliance with this standard.
Plan of Correction:	The Administrator completed a fall risk rating on resident 3 and will update it after a fall and on annual basis.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review and staff interview, the facility failed to ensure all private pay uniform assessment instruments (UAIs) are completed as required by 22VAC30-110. Evidence: 1. Resident 3's 4/1/19 UAI assessed mechanical help only with stair climbing. Staff 2 confirmed resident 3 receives mechanical help and physical assistance for stair climbing.
Plan of Correction:	1. The Individualized Service Plan for resident for resident #3 updated to reflect human help with physical assistance with stair climbing as identified on the updated Uniformed Assessment Instrument.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review and staff interview, the facility failed to ensure all ISPs are signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. This requirement applies to plan reviews and updates. Evidence: 1. Resident 4's 9/21/18 UAI had 2 revisions done in April 2019. Staff 2 confirmed new signatures were not obtained from the facility nor resident.
Plan of Correction:	The Administrator shall ensure that all individualized service plans are signed and dated by the person who completed the plan and by the resident or his legal representative. Resident 4?s individualized service plan was signed by resident on 6/14/19.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and staff interview, the facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. Resident 1 is prescribed humalog kwikpen insulin on a sliding scale. The physician's order prescribes a phone call for readings greater than 400. On 5/4/19, the facility failed to document contacting the facility when the 5 pm reading was greater than 400. Staff 4 was unable to provide documentation to demonstrate compliance with this standard.
Plan of Correction:	1. The Administrator would ensure that all medications administered for residents are consistent with physician?s or other prescriber?s instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Blood sugar readings will be reported to the prescriber as required in the order and instruction. 2. Medication Refresher on medication administration conducted for staff 4 on hyperglycemia and hypoglycemia