VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Evergreen Assisted Living Community
1437 Peter's Creek Road, NW
Roanoke, VA 24017
(540) 526-8022

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: Aug. 9, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

250-C

Comments:

A monitoring inspection was initiated on 8/9/2021 and concluded on 8/12/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was three. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed two resident records, two staff records, discharge documentation, the Sworn Disclosure Statement and Criminal Record Report for all new staff members, resident roster, staff roster, staff schedule, facility healthcare oversight, fire and emergency drills, health department inspection, and dietician oversight submitted by the facility to ensure documentation was complete submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 8/11/2021. An exit interview was conducted with the administrator after the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. 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 #:	22VAC40-73-450-C
Description:	450-C Based on record review, the facility failed to ensure the comprehensive individualized service plan (ISP) shall include a written description of identified needs based upon the uniform assessment instrument (UAI), as well as a written description of what services will be provided to address identified needs. EVIDENCE: 1. The UAI for resident 2, dated 8/25/2020, indicated that the resident is disoriented to some spheres some of the time which includes delusions about being pregnant; however, the ISP for resident 2, dated 10/2/2020, does not identify or address this disorientation. 2. The ISP for resident 2, dated 10/2/2020, indicated that the resident needs mental health services which will be provided during scheduled appointments at Blue Ridge Behavioral Health; however, the ISP does not indicate which mental health services will be provided in order to address identified needs.
Plan of Correction:	The Administrator will ensure that all identified needs of residents on the Uniform Assessment Instrument have a corresponding written description of what services will be provided to address the identified needs.
Standard #:	22VAC40-73-650-B
Description:	650-B Based on record review, the facility failed to ensure that physician or other prescriber orders shall identify the diagnosis, condition, or specific indications for administering each drug. EVIDENCE: 1. The signed physician orders for resident 1 failed to include a diagnosis for the following medications: Depakote 500 mg delayed release tablet, written 4/12/2021; Clozapine 25 mg tablet, written 4/12/2021; Benztropine 2 mg tablet, written 4/12/2021; Lisinopril 20 mg tablet, written 5/19/2021; Haldol Decanoate 100 mg/mL solution injection, written 4/12/2021; Acetaminophen 500 mg tablet, written 6/15/2020. 2. The signed physician orders for resident 2 failed to include a diagnosis for the following medications: Benztropine 1 mg oral tablet, written on 5/21/2021; Docusate Sodium 100 mg oral capsule, written on 5/26/2021; Metformin 500 mg tablet, written on 5/18/2021; Propranolol 40 mg oral tablet, written on 5/21/2021; Clonzapine 100 mg oral tablet, written on 5/21/2021; Fluphenazine 10 mg oral tablet, written on 5/21/2021; Polyethylene Glycol 3350 17 g/dose oral powder, written on 5/27/2021; Atorvastatin 40 mg tablet, written on 5/18/2021; Melatonin 3 mg oral tablet, written on 5/21/2021; Lithium 450 mg oral tablet extended release, written on 5/21/2021; Trazodone 150 mg oral tablet, written on 5/21/2021.
Plan of Correction:	The Administrator will re-enforce to all HCP who prescribe medications to residents to include diagnosis or indications for use with the order for administering each drug.