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: July 7, 2019 and July 19, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

On 7/17/2019 one inspector began a complaint investigation (2:20pm to 3:05pm), and concluded on 7/19/2019 (4:20pm to 4:30pm). The complaint alleged that a resident was woken up against his will and had a brief changed when he didn?t want it changed. The complaint further alleged that a pink female brief was used. There is no available evidence to support what color the brief was. The evidence shows that the resident was awoken in the middle of the night and he didn?t want to be, and that he was changed. The complaint is valid.

Violations:

Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on resident record review, the facility failed to complete a uniform assessment instrument (UAI) in accordance with Assessment in Assisted Living Facilities (22VAC30-110). EVIDENCE: 1. The UAI for resident 1, dated 3/22/2019, lacked assessments for eating/feeding, continence of bowel, continence of bladder, walking, wheeling, stair climbing, mobility, and was also lacking the signature of the administrator.
Plan of Correction:	The needs and services on the UAI have been updated to more accurately address resident #1. Going forward the Clinical Manager will spend uninterrupted time reviewing and revising the UAI.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on interview and documentation, the facility failed to address a resident need on a comprehensive individualized service plan (C-ISP). EVIDENCE: 1. Resident progress notes and interviews with several facility staff show that resident 1 is sometimes incontinent of bladder, and this need is not addressed on the C-ISP dated 3/22/2019.
Plan of Correction:	The needs and services on the ISP have been updated to more accurately address resident #1. Going forward the Clinical Manager will spend uninterrupted time reviewing and revising the ISP of residents and attend the next ISP training session that is available.
Standard #:	22VAC40-73-550-C
Complaint related:	Yes
Description:	Based on documentation and interviews, the facility failed to respect a resident's rights. EVIDENCE: 1. Resident 1 was not treated with dignity. Resident 1's disposable brief was changed at approximately 2:30am on 6/12/2019, according to Resident Progress Notes and interviews with family, resident 1, and caregivers. The resident was unhappy with being woken up for this, and did not want to be changed. Two staff members ended up being involved in changing the disposable brief.
Plan of Correction:	Resident #1 has requested to not be awakened at night for changing his incontinence brief even if he is wet and his family support has agreed with this request. Staff is updated to allow the resident to sleep all night and not approach for changing the incontinence brief. The ISP has been updated to reflect this request.