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: May 5, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector and licensing administrator were on-site at the facility for each day of the inspection: 05/05/2022 10:55AM through 1:15PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of resident records reviewed: 2 Number of staff records reviewed: 1 Observations by licensing inspector: licensing inspector conducted one medication cart audit to follow-up on previous high-risk violations. Additional Comments/Discussion: This inspection was conducted as the first of two inspections required for the facility?s current Provisional license. Violations were followed up on from the facility?s last mandated inspection. Licensing inspector was under the supervision of the licensing administrator. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to ensure that resident personal and social information contained all required components. EVIDENCE: The ?Resident ? Personal/Social Data? document for resident 1, admission date 04/07/2022, did not include the following required components: responsible individual, local department of social services, other agency, previous mental health or intellectual disability history and current behavioral and social functioning problems.
Plan of Correction:	Corrected on day of inspection, the social data was properly filled in. Facility will make sure on day of admission all areas of social data will be completed with manager supervision.
Standard #:	22VAC40-73-640-A
Description:	Based on resident record review and document review, the facility failed to implement their medication management plan. EVIDENCE: 1. The facility?s medication management plan states the following: ?Proper handling of refused or dropped medications 1.) If medication is refused, waste the medication and circle initials on M.A.R.S. (medication administration record). Also, document on the back of the M.A.R. the reason for wasting the medication and notification to Administrator/Assistant Administrator, and Physician shall follow with documentation, and follow pharmacy policy. 2. The April and May 2022 MARs for resident 1 contained documentation that the resident refused his prescribed Ibuprofen and Simethicone numerous days during April 2022 and every day in May 2022 from 05/01/2022 through 05/05/2022. The record for resident 1 did not contain documentation that the resident?s physician had been notified about the resident?s refusals.
Plan of Correction:	Facility management will monitor to ensure all medications that a resident has the right to refuse, the physician will be notified and chart documented daily or as often as needed. The facility will adhere to their policy and make sure physician and chart will be documented as often as needed. Facility now uses QMAR system for documentation.
Standard #:	22VAC40-73-680-K
Description:	Based on resident record review, the facility failed to ensure that a PRN (as needed) medication order included the exact dosage of the PRN medication for a resident. EVIDENCE: The record for resident 1 contained a physician?s order, dated 04/13/2022, for the following: Hydroxyzine HCL tablet take 25- 50MG by mouth every night at bedtime as needed for insomnia.
Plan of Correction:	The physician was notified on day of inspection and corrected. Was sent to the facility and facility pharmacy on 5- 6-22 noted in chart. Management will monitor and check as orders are received in facility.