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: May 29, 2020 and June 1, 2020

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 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 monitoring inspection was initiated on 5/27/2020 and concluded on 6/1/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 36. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, background checks on new staff, health care oversight, fire inspection report, Fire and Emergency drill logs, staff schedules, and the dietitian oversight report were reviewed, submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on staff record review, the facility failed to have a TB evaluation completed for a staff person. EVIDENCE: 1. Staff 1 was hired on 1/31/2020. The TB evaluation for staff 1, dated 1/30/2020, shows that part II of the evaluation needed to be completed, and it was left blank.
Plan of Correction:	1. The TB evaluation for Staff 1 was corrected to include part II of the evaluation. All other staff members TB evaluations were audited for completeness. Going forward the Assisted Living Administrator and Human Resource Department will audit each new hire TB test for completeness.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to completely address needs on updated individualized service plans (ISP). EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 1 dated 4/9/2020 shows this resident is disoriented to date and time some of the time. The ISP dated 4/9/2020 does not address which spheres the resident is disoriented to. 2. The UAI for resident 3 dated 2/4/2020 shows this resident requires mechanical and human help (supervision) with toileting. The ISP dated 4/9/2020 shows the resident needs mechanical and physical (supervision) assistance; however, the description of services does not address mechanical assistance, and does not show supervision - to describes hands-on assistance. 3. The UAI for resident 3 dated 2/4/2020 shows this resident is disoriented to date, time, place, and date of birth all of the time. The ISP dated 4/9/2019 does not show what the resident is disoriented to. The service is described as "Will provide frequent orientation and reminders to resident." It does not show what the resident will be oriented to or what they will be reminded of.
Plan of Correction:	1. The ISP for resident 1 was updated to address which spheres the resident is disoriented too as described on resident?s UAI. All resident ISP?s were audited and corrected to address spheres that each resident is disoriented to. 2. The ISP for resident 3 was corrected to include a description of mechanical assistance and supervision assistance as described on resident?s UAI. Going forward the Clinical Manager will spend uninterrupted time reviewing and revising the UAI and ISP of residents. 3. The ISP for resident 3 was updated to address which spheres the resident is disoriented too as described on resident?s UAI. All resident ISP?s were audited and corrected to address spheres that each resident is disoriented to.
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to ensure that a complete oxygen order was obtained. EVIDENCE: 1. The oxygen order for resident 2 lacks identification of the source(s) of oxygen.
Plan of Correction:	1. The oxygen order for resident 2 was updated to include source of oxygen. All other residents resident oxygen orders were reviewed and corrected to include the source of oxygen on the order. Going forward the Clinical Manager will review orders periodically to ensure completeness.