VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brandon Oaks
3804 Brandon Avenue SW
Roanoke, VA 24018
(540) 776-2600

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.

Comments:

On 6/11/2019 one inspector (LI) conducted a renewal study (9:50am to 7:30pm). 38 residents were in care, with 11 of them in the special care unit (memory care). Eight resident charts were fully reviewed, four staff records, and one sitter record were fully reviewed, with partial reviews of new staff records for background checks. Two medication passes were observed, residents, family, and staff were interviewed, meals and activities were observed, and a physical plant tour was done. At the conclusion of the inspection, the exit interview was held and the facility provided some additional documentation to support that some violations had not occurred. Management staff and the LI discussed ways to document emergency plan reviews with staff, residents, volunteers, and sitters, Please respond to the violation notice by 6/29/2019 or sooner. If you have questions, you may contact the licensing inspector at 309-3043. NOTE: this renewal inspection is not counted as mandated because it was done in the same fiscal year as the prior renewal study, which was done closer to the expiration date.

Violations:

Standard #:	22VAC40-73-290-A
Description:	Based on document review, the facility failed to have a written work schedule with an indication of which one staff person was in charge at any one time [in the absence of management staff]. EVIDENCE: 1. The facility has two staff schedules for separate units in the same building, under the same license. The schedules show two separate people in charge [in the absence of management staff}.
Plan of Correction:	1. Even though Brandon Oaks AL has 2 distinct units under one license, there will be one person listed in charge on the staff schedule in the absence of management staff. The schedule was also corrected for June, 2019. This will be the responsibility of the Administrator and Clinical Manager.
Standard #:	22VAC40-73-320-A
Description:	Based on review of resident records, the facility failed to obtain required information on a resident pre-admission physical exam. EVIDENCE: 1. The physical exam for resident 2, dated 1/7/2019, shows this resident has an allergy to penicillin; however, the reactions to penicillin are not noted.
Plan of Correction:	The physical exam for resident #2 has been updated by the PCP to discontinue the allergic reaction to Penicillin. All new residents entering assisted living will have the reaction for any allergies documented on their history and physical and this will be the responsibility of the Clinical Manager.
Standard #:	22VAC40-73-390-C
Description:	Based on resident record review, the facility failed to have an updated, current resident agreement in a resident chart. EVIDENCE: 1. The resident agreement for resident 6 dates from August 2017 and it hasn't been updated to include required sections of the agreement. The new sections became required when the regulations changed in 2018.
Plan of Correction:	The updated resident agreement for resident #6 has been signed and added to the resident chart. All current residents will sign the new resident agreement and also sign if additions are made in the future. All new residents will sign the new agreement at admission. This will be the responsibility of the admitting nurse, Administrator and Clinical Manager.
Standard #:	22VAC40-73-450-C
Description:	Based on review of resident records, the facility failed to address an assessed resident need on a comprehensive individualized service plan (C-ISP). EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 1, dated 5/23/2019, shows this resident is incontinent weekly or more. This is not addressed on the ISP dated 2/19/2019. The UAI for resident 1 shows this resident needs mechanical assistance when toileting, and the ISP shows the service as "Grab bars will be provided in bathroom and rolling walker will be used while resident is ambulating. " The UAI for resident 1 shows the resident requires supervision with mobility [outside the facility], and the ISP has two separate entries to show services. The first one shows the service to be given for this is "Rolling walker will be used while ambulating", and the second one states that resident will have family or staff member when out of our facility. By splitting the services into two sections, on separate pages, the ISP can cause confusion about what exactly must be done. The UAI for resident 1 shows the resident needs mechanical help only while climbing stairs, and the ISP shows that supervision is given. The UAI for resident 1 shows this person is disoriented to some spheres (place, time, and date) all of the time. The ISP does not fully address the disorientation, "Resident will have cues and reminders for meals and activities." 2. The UAI for resident 7, dated 5/13/2019, shows this resident needs mechanical and human help with physical assistance with bathing, and the ISP does not show the nature of the physical assistance or mechanical assistance. The UAI for resident 7 shows this resident needs mechanical help only with walking, and the ISP shows the service to be provided for this is "Resident will be reminded in teh mornings to put on clean clothes & not too many layers."
Plan of Correction:	1. The needs and services on the UAI and ISP have been updated to more accurately address resident #1. Going forward the Clinical Manager will spend uninterrupted time reviewing and revising the UAI and ISP of residents and attend the next ISP training session that is available. 2. The needs and services on the UAI and ISP have been updated to more accurately address resident #7. Going forward the Clinical Manager will spend uninterrupted time reviewing and revising the UAI and ISP of residents and attend the next ISP training session that is available.
Standard #:	22VAC40-73-450-D
Description:	Based on document review, the facility failed to have hospice services for a resident on an individualized service plan (ISP). EVIDENCE: 1. The ISP for resident 2 shows that hospice services began on 4/5/2019, however, the services provided by hospice are not described.
Plan of Correction:	1. The ISP for resident #2 is updated to include all hospice services on the hospice care plan and this will be kept up to date going forward. All current and future hospice residents will have hospice services included on their plan of care by the Clinical Manager.
Standard #:	22VAC40-73-660-B
Description:	Based on observation and resident record review, the facility failed to ensure that a resident keeping medication in her room was assessed as being capable of self-administering medication. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 3, dated 3/12/2019, shows this resident requires assistance to administer medications. The bathroom in resident 3's bedroom contained the following medications: Biofreeze, IcyHot, Deep Sea nasal spray, and Thermal Care Heat Wrap.
Plan of Correction:	1. Resident #3 had medications removed from her apartment on the day of the inspection and discarded that were not approved for self-administration or to be kept in the apartment. The administrator informed the resident?s family and had a conversation with the resident regarding purchasing medications when she goes shopping and not informing staff. The Administrator or Clinical Manager will check resident?s apartment periodically for unapproved and undocumented medications and this was agreed to by the resident. This intervention was added to the resident?s ISP. If resident wants to administer medications she purchases, physician?s orders will be obtained for the resident to self-administer and store in her apartment. This will be the responsibility of the Administrator and Clinical Manager.