VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Candis Assisted Living
1619 Hanover Ave
Roanoke, VA 24017
(540) 343-8640

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

Inspection Date: Feb. 16, 2022

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.

Technical Assistance:

To ensure that the facility had a thorough understanding of the standards, the LIs had a discussion with the owner and the administrator regarding standards 22VAC40-90-40-B and 550-G.

Comments:

The licensing inspector (LI) for Candis Assisted Living, along with another LI conducted an unannounced renewal study on 02/16/2022 from 8:19AM until 5:00PM, finding 13 residents in care. The inspection included a tour of the physical plant, observation of a medication pass, a review of the medication storage carts and staff/resident interviews. Six resident records were thoroughly reviewed. Sworn disclosure statements and criminal record checks were examined for all newly hired staff, and the records of 3 staff were thoroughly examined. Additional facility documentation was surveyed for compliance with the Standards for Assisted Living Facilities. Findings were reviewed with facility staff during the inspection. An exit interview was conducted with the Administrator and the Owner on 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. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 589-5216.

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on resident record review, the facility failed to ensure that the statement prepared and provided to the prospective resident that discloses information about the facility included all required components. EVIDENCE: The record for resident 4 contained the document ?Assisted Living Facility Disclosure Statement? that was signed by the resident on 03/22/2021. The disclosure statement did not include a description of all accommodations, services and care that the facility offers or the categories, frequency, and number of activities provided for residents.
Plan of Correction:	Owner corrected during inspection with admin. Will make sure going forward all info is on disclosure as required.
Standard #:	22VAC40-73-120-C
Description:	Based on staff record review, the facility failed to ensure that all staff shall be trained in the relevant laws, regulations, and the facility?s policies and procedures sufficiently to implement requirements and procedures for detecting and reporting suspected abuse, neglect, or exploitation of residents and for mandated reporters, the consequences for failing to make a required report, as set out in 63.2-1606 of the Code of Virginia. EVIDENCE: The new staff training documentation for staff 2, hired 10/8/2021, did not contain documentation that staff 2 was trained on the relevant laws, regulations, and facility?s policies and procedures for mandated reporters.
Plan of Correction:	Completed day of inspection. Was done and mandated reporter but not documented. All documentation will be written down and contained in staff folder. Mandated reporter in-service to be given again to staff and all staff.
Standard #:	22VAC40-73-325-B
Description:	Based on resident record review, the facility failed to ensure that the fall risk rating shall be reviewed and updated after a fall. EVIDENCE: 1. The nurses notes for resident 6, dated 1/26/2022, indicated that the nurse on duty heard something hit the floor at around 11:45 AM. When investigated, resident 6 was discovered sitting on the floor in front of his chair. 2. The record for resident 6 did not contain a fall risk assessment as a result of the documented fall on 1/26/2022.
Plan of Correction:	In-service will be provided to all nurses to reinforce documentation of all risk assessment protocol once a month per all [sic] to make sure all assessments are completed in timely manner.
Standard #:	22VAC40-73-350-B
Description:	Based on resident record review, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. EVIDENCE: Resident 4 was admitted to the facility on 03/23/2021. The record for resident 4 contained documentation that the search on the sex offender registry to ascertain whether or not the resident is a registered sex offender was not completed until 11/22/2021.
Plan of Correction:	The sex offender site was done and [sic] wrong person (picture). Was sent again and received. All residents prior to admission will have sex offender form.
Standard #:	22VAC40-73-640-A
Description:	Based on observation during audit of the facility?s main medication cart, the facility failed to implement methods to prevent the use of outdated medications. EVIDENCE: 1. The facility?s medication management plan states the following: ?2. All Candis registered medication aides, licensed professional nurses will follow the guidelines of our pharmacy Omi Care on oral, enteral, ophthalmic, OTIC, and topical medications and all medication will be dated and initial when opened. (see guidelines attached).? The Omnicare medication storage guidance that is part of the facility?s medication management plan states the following: ?Xalantan Ophthalmic Solution (latanoprost) ? date when opened and discard after 6 weeks.? 2. The record for resident 1 contained a physician?s order, dated 07/12/2021, that stated ?Latanprost 0.005% Drops ? place 1 drop as directed at bedtime?. 3. The record for resident 2 contained a physician?s order, dated 09/23/2021, that stated ?Latanprost 0.005% Drops ? install 1 drop in both eyes at bedtime?. 4. During the facility?s on-site inspection on 02/17/2022, one licensing inspector (LI) observed two opened bottles of latanprost 0.005% eye drops that had been opened and used for both residents 1 and 2. Neither bottle contained the date that the bottles had been opened by staff.
Plan of Correction:	Corrected day of inspection. All LPNs and RMAs will be in-serviced and reinforce in the policy guidelines on oral, internal, ophthalmic, topical medications and all medications to be dated and initialed when open.
Standard #:	22VAC40-73-650-B
Description:	Based on resident record review, the facility failed to ensure that physician or other prescriber orders for administration of all prescription and over-the counter medications and dietary supplements identified the diagnosis, condition, or specific indications for administering each drug. EVIDENCE: 1. The following medications on the physician?s orders, dated 07/21/2021, for resident 1 did not include the diagnosis, condition, or specific indications for administering the following drugs: atorvastatin calcium f/c 80 MG and quetiapine fumarate f/c 50 MG. 2. The following medications on the physician?s orders, dated 09/23/2021, for resident 2 did not include the diagnosis, condition, or specific indications for administering the following drug: latanoprost 0.005% drops. 3. The following medications on the physician's orders, dated 2/1/2022, for resident 3 did not contain a diagnosis, condition, or specific indications for administering the following drugs: Amantadine 100 mg tab, Benztropine Mesylate 1 mg tab, Divalproex Sodium 500 mg tab, Fiber Laxative 500 mg tab, Omeprazole 40 mg cap DR, Polyethylene Glycol 3350 17 gm/dose powder, Tamsulosin HCL 0.4 mg cap, Trazodone HCL 100 mg tab, and Trihexyphenidyl U-D 5 mg tab.
Plan of Correction:	All nurses and RMAs will be in-serviced on physicians' order and will include diagnosis on all prescribing orders, Facility will check with physician often for diagnosis. And Resident #3 new psy doctor okay to put in dx. Paperwork was sent to drs office was never received after requesying several times.
Standard #:	22VAC40-73-680-B
Description:	Based on observation during audit of the facility?s main medication cart, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to residents. EVIDENCE: During the facility?s on-site inspection on 02/16/2022, one licensing inspector (LI) observed the following pills that were not in the pharmacy issued container laying loose in the bottom of the drawers of the facility?s main medication cart: 12 whole pills of various colors, shapes and sizes and 2 half pills in the second drawer; 3 white, round pills and 1 white, oblong pill in the third drawer; and 1 white, round pill, 1 red, round pill and 1 white, oblong pill in the fourth drawer of the facility?s main medication cart.
Plan of Correction:	Loose pills were immediately placed in sharp container. In-service will be done with LPNs and RMAs on dispensing medications from bottles and from any dropped pills to be disposed of immediately in sharp container. All medications are given to residents in a timely manner and [sic] of properly. Med carts to be audited daily by nurses and RMAs and audited by management weekly.
Standard #:	22VAC40-73-680-M
Description:	Based on observation during audit of the facility?s main medication cart, the facility failed to ensure that medications ordered for PRN (as needed) administration are available at the facility. EVIDENCE: The record for resident 3 contained a physician?s order, dated 02/01/2022, for ?selenium sulfide 1% suspension ? 1 application by topical route as directed (rash, irritation) 3-ML to bilateral axilla/arm-put as needed?. During the facility?s on-site inspection on 02/17/2022, one licensing inspector (LI) was not able to locate this medication in neither one of the facility?s two medication carts. Interview with staff 1 confirmed that this medication was not available at the facility on this date.
Plan of Correction:	PRN medication was ordered from pharmacy day of inspection and received that day. All nurses, RMAs will be in-serviced on PRN medications and policy for keeping PRN always available.