VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Meadow Hills Assisted Living Facility
5046 Williamson Road
Roanoke, VA 24012
(540) 400-7253

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: Aug. 2, 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 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 Meadow Hills Assisted Living Facility conducted an unannounced renewal study at the facility on 8/2/19 from 8am until 4pm and noted 23 residents to be in care. Resident and staff records as well as other forms of facility documentation were reviewed and interviews were conducted with residents and staff. The morning medication pass was observed and the mid day meal was viewed. The LI discussed with the facility that a new medication reference manual will be needed before the end of the year. The LI also reviewed best areas for storage of facility policy and procedures for all employees to have access. If you have any questions please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on a review of staff records, the facility failed to ensure and all direct care staff received at least 18 hours of training annually. EVIDENCE: 1. The record for staff person 1, hired on 3/9/16, has documentation that the employee has only received 4.5 hours of annual training between March 2018 and March 2019. 2. The record for staff person 3, hired on 7/4/16, has documentation that the employee has only received 1 hour of annual training between July 2018 and July 2019.
Plan of Correction:	The Administrator/designee will schedule trainings and in-services to ensure that these employees are caught up on all required training. The administrator/office assistant will monitor employee trainings regularly to ensure that all staff receive all required hours of training annually.
Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records,the facility failed to ensure that all direct care staff maintained current certification in first aid. EVIDENCE: 1. The record for staff person 1, hired on 3/9/16, has documentation that their certification in first aid expired on 5/11/18.
Plan of Correction:	The Administrator will have staff person 1 attend a first aid class and will review all staff records regular to ensure that first aid is kept current for all direct care staff.
Standard #:	22VAC40-73-270-4
Description:	Based on a review of staff records, the facility failed to ensure that direct care staff were trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents annually. EVIDENCE: 1. The records for staff person 1, hired on 3/9/16 and staff person 3, hired on 7/4/16 does not have documentation that the employees have received annual training for residents with aggressive behaviors. The facility does house a mental health population of which some residents have a history of aggressive behaviors.
Plan of Correction:	An aggressive behavior training has been scheduled for this month and the administrator will ensure that all direct care staff have aggressive behavior training annually.
Standard #:	22VAC40-73-310-B
Description:	Based on a review of resident records, the facility failed to ensure that a interview between the administrator or a designee responsible for admission and retention decisions, the individual, and his legal representative was documented. EVIDENCE: 1. The records for resident 1, admitted on 7/1/19 and resident 2, admitted on 1/11/19 did not contain documentation of an interview that occurred between the administrator or a designee responsible for admission and retention decisions, the individual, and his legal representative.
Plan of Correction:	The administrator/designee will develop a form to ensure that pre admission interviews are documented.
Standard #:	22VAC40-73-430-H-2
Description:	Based on a review of resident records, the facility failed to maintain a copy of a discharge statement in resident records. EVIDENCE: 1. The record for resident 7, discharged from the facility on 3/28/19, did not contain a copy of the residents discharge statement.
Plan of Correction:	The administrator/office assistant will ensure that a copy of discharge statements are placed in resident records at the time of discharge.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to address all identified needs on individualized service plans (ISPs). EVIDENCE: 1. The public pay uniform assessment instrument (UAI) dated 1/4/19 in the record for resident 2 has that the resident requires mechanical assistance with transferring, walking and mobility. The comprehensive ISP dated 5/8/19 does not address these identified needs. Staff person 4 expressed that resident 2 does use a rolling walker for these ADL needs. 2. The public pay UAI dated 6/21/19 in the record for resident 4 has that the resident requires mechanical assistance for mobility. The comprehensive ISP dated 5/16/19 does not address this identified need. Staff persons 1 and 4 expressed that resident 4 uses a cane for mobility.
Plan of Correction:	The administrator/designee will update resident 2 and 4's ISP's to reflect current identified needs. Resident ISP's will be reviewed/audited regularly to ensure that all identified needs are on the plans.
Standard #:	22VAC40-73-520-I
Description:	Based on observations, the facility failed to post a monthly activity schedule. EVIDENCE: 1. The facility posted activity schedule was noted to be only for the current week and not the entire month.
Plan of Correction:	The administrator/designee will ensure that the posted activity calendar is for the entire month.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of resident records, the facility to ensure that a review of resident rights and responsibilities occurred with all residents annually. EVIDENCE: 1. The record for resident 3, admitted on 10/18/16 has documentation that the last review of resident rights and responsibilities conducted with the resident occurred on 1/13/18.
Plan of Correction:	The administrator will conduct a review of resident rights with resident 3 and will ensure that all residents receive resident right reviews annually.
Standard #:	22VAC40-73-610-D
Description:	Based of a review of resident records, the facility failed to ensure that a diet ordered by a physician was prepared and served according to the physician order. EVIDENCE: 1. The history and physical dated 6/20/19 in the record for resident 1 has a physician order for a 1800 calorie ADA diet. Per interviews with staff person 4 and 5 resident 1 is not receiving a 1800 calorie diet as this diet is not offered at the facility and resident 1 has a physician appointment on 8/21/19 to discuss changing the diet.
Plan of Correction:	The administrator/designee placed a call to the residents physician on the day of inspection to have the diet order clairified. The administrator/designee will review all admission paperwork prior to a new residents admission and will have diets clarified before the arrival of any new resident.
Standard #:	22VAC40-73-640-A
Description:	Based on observations, the facility failed to implement their medication management plan. EVIDENCE: 1. The facility medication cart contained a open bottle of Novolog insulin for resident 5. The bottle did not contain an open date to ensure that it is disposed of in 28 days per manufacturer instructions. The facility medication management plan states that the administrator or designated staff inspects containers regularly for expiration dates.
Plan of Correction:	The administrator will set up in-services with all medication aides to review facility policy and procedures for proper dating of opened insulin.