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 9, 2021 and June 10, 2021

Complaint Related: No

Areas Reviewed:

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 renewal inspection was initiated on 6/10/2021 and concluded on 6/11/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 39. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed three (3) resident records, three (3) staff records, staff schedules, fire drill records, background check review on new staff, health care oversight report, fire inspection report, health department report, medication management plan, and infection control policy 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 #:	22VAC40-73-100-C-2
Description:	Based on document review, the facility's infection control plan did not fully address a required section of the plan. EVIDENCE: 1. The part of the facility's plan entitled INJECTABLE MEDICATION ADMINISTRATION does not address the use of safe injection practices and other procedures where the potential for exposure to blood or body fluids exists.
Plan of Correction:	The Injectable Medication Administration policy will be updated to address the use of safe injection practices and other procedures where the potential for exposure to blood and bodily fluids exits.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review, the facility failed to complete uniform assessment instruments (UAI) in accordance with Assessment in Assisted Living Facilities (22VAC30-110). EVIDENCE: 1. The UAI for resident 1 dated 05/04/2021 has two entries for mobility. Both Mechanical & Human Help with Supervision and Confined Moves About were selected. 2. The UAI for resident 2 dated 04/27/2021 has two entries for mobility. Both Mechanical & Human Help with Supervision and Confined Moves About were selected.
Plan of Correction:	The mobility section of the UAI for resident 1 has been updated and is accurate. The mobility section of the UAI for resident 2 has been updated and is accurate.