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 6, 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 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:

The facility requested information regarding timing of medication administration times. LI will email it to the facility. There was a discussion regarding various practices of documenting narcotic counts at change of shift.

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/6/2022, 8:45 am to 2 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 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 Susan Mallory, Licensing Inspector at (540) 309-3043 or by email at susan.mallory@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-220-A
Description:	Based on staff record review, the facility failed to have some required information in the record for private duty personnel. EVIDENCE: 1. The record for staff 4, who is a private duty companion for resident 7, lacks information regarding information on the type and frequency of the services to be delivered to the resident by private duty personnel.
Plan of Correction:	Administrator or designee will ensure all private duty files are complete prior to beginning services and will audit files periodically to ensure compliance.
Standard #:	22VAC40-73-260-A
Description:	Based on staff record review, the facility failed to ensure a new direct care staff person had first aid training within 60 days of hire. EVIDENCE: 1. Staff 2, who was employed on 11/9/2022, obtained first aid training on 2/24/2022. This was noted on 6/6/2022.
Plan of Correction:	Administrator or designee will ensure all staff obtain first aid training within 60 days of hire and will audit employee files periodically to ensure compliance.
Standard #:	22VAC40-73-680-C
Description:	Based on observation and resident record review, the facility failed to administer medications within one hour of the scheduled time. EVIDENCE: 1. Resident 2 had several medications scheduled to be administered at 8 am, and on the day of the inspection, they were administered at 9:35 am. The medications were: Lisinopril, Magnesium Oxide, Aspirin, Calcium, and Eye Multivitamins.
Plan of Correction:	Nursing staff was educated on the med management policy regarding medication administration times on the day of inspection. Clinical Manager will do periodic audits to ensure medications are being administered on time.