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 and Feb. 18, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

The licensing inspector (LI) for Candis Assisted Living conducted an unannounced focused monitoring inspection on 02/16/2022 to follow up on two self-reported incidents of a resident elopement by the facility on 10/19/2021 and 12/31/2021. The LI requested additional documentation from the facility via phone on 02/18/2022 to complete the self-reported incident investigation. Findings were reviewed with facility staff during the on-site inspection. A preliminary exit interview was conducted with the Administrator and Owner on the date of inspection and a telephone exit interview with conducted with the Owner on 02/18/2022, 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 #:	22VAC40-73-1020-A
Description:	Based on facility document review, the facility failed to ensure when residents are present, there are at least two direct care staff members awake and on duty at all times in each building who are responsible for the care and supervision of the residents. EVIDENCE: 1. The facility serves a mixed population based on documents provided to the licensing inspector by the facility. 2. Staff schedule provided by staff 5 showed staff 3 was the only direct care staff member on duty during third shift (8 PM until 7 AM) on 10/18/2021 and staff 4 was the only direct care staff member on duty during second shift (3 PM until 11 PM) on 12/30/2021 when resident 1 was reported as eloping from the facility during both of these dates. 3. The staff schedule also shows the following: time period 10/19/2021 through 01/02/2022 there was only one direct care staff member on duty during third shift for each of these days and there were multiple days also during this time period that there was only one direct care staff member on duty during first and second shifts.
Plan of Correction:	2 direct care staff will be on duty each shift awake and on duty at all times for care and supervision of the residents.
Standard #:	22VAC40-73-460-D
Description:	Based on resident record review and document review, the facility failed to ensure supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises. EVIDENCE: 1. The record for resident 1 contained a uniform assessment instrument (UAI) completed by staff 1, dated 03/10/2021, that contained the following information: ?behavior pattern: wandering/passive ? less than weekly?, ?type of inappropriate behavior: can wander within facility trying to find his room. Staff re-directs often? and ?orientation: disoriented ? some spheres, some of the time ? spheres affected: place?. 2. The ?Report of Resident Physical Examination? for resident 1, dated 03/11/2021, contained documentation that the resident has frontotemporal dementia. 3. Resident 1 was admitted to the facility on 03/23/2021. 4. The licensing inspector (LI) for the facility received a self-report from the facility by staff 2 on 10/19/2021 that ?rsd. Eloped from the building? and ?last seen at 3:45AM?. The staff member in charge at the time was staff 3. 5. Nurse?s notes for the resident contained the following documentation by staff 3 on 10/19/2021 at 3:15AM: ?When I checked, he was in bed, I went in (another resident) room to change him, then went upstairs checked on the other rsds [sic], came back directly to the office to do my paperwork, I went to check on them and he was not in the room check everywhere then I called 911 and the [sic] told me he is in the hosp.? Staff 2 stated that the resident was admitted to the hospital for ?altered mental status?. 6. The UAI for resident 1 was updated by staff 2 on 11/17/2021 with the following information: ?disoriented ? some spheres, all the time ? spheres affected: place, year, date?. 7. The LI for the facility received another self-report from the facility by staff 2 regarding resident 1 on 12/31/2021 containing the following information: ?date and time of incident 12/30/2021 at 6:30 pm, rsd (resident) was given meds around 5:00pm. Called rsd to come eat dinner rsd did not come went downstairs to get him rsd was not in site. Search all the rooms for rsd still couldn?t find him. Notified police and (the owner and administrator). Rsd was found on side walk (11:30 pm) by staff (staff 4) and brought back to facility.? 8. Nurses? notes for the resident contained the following documentation by staff 4 on 12/30/2021 at 11:36 pm ?found rsd laying on sidewalk with drink and chips. Rsd stated that he lost his balance and fell. Rsd was alert and oriented to name and last four of social to give to VA. No visible bruises. A skin tear was on the left elbow, cleaned and bandaged it up. Rsd had some scratches on both knees. VA emergency is on a diverson [sic]. Rsd will go to VA PCP to get check out. Rsd was given night time medication. Rsd is currently laying in bed (owner and administrator) notified. When rsd was found on sidewalk, called 911 and EMS and a police officer arrived. EMS check [sic] him out and took his vitals." 9. According to timeandate.com, the temperature for 12/30/2021 from 6:54PM until 11:54PM was between 59 degrees Fahrenheit and 56 degrees Fahrenheit with foggy conditions. 10. The individualized service plan (ISP) for resident 1 was updated on 01/03/2022 by staff 2 to reflect that the resident now has a project lifesaver bracelet that staff are to check daily on the resident?s left wrist and to check the battery weekly.
Plan of Correction:	Resident has no order to stay in facility and only goes around all over facility. He handles his finances and can assist himself as needed. Resident left facility on his own w/o notifying staff and wanted to go find his blue van he had at VA. The facility will ensure Resident is safe at all times going forward and will have physician to re-examine him for further psy. evaluation. Salem VA Community care program also monitors resident monthly.