VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Meadow Hills Assisted Living Facility
5046 Williamson Road
Roanoke, VA 24012
(540) 400-7253

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

Inspection Date: July 27, 2022

Complaint Related: No

Areas Reviewed:

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/27/2022 08:30 AM ? 04:00 PM 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on resident record review, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety or welfare of any resident. EVIDENCE: 1. The record for resident 4 contained the following emergency room documentation, dated 05/17/2022, ?Patient wheeled to triage. Reports tripping over a wire, falling and landing on right side. This event happened yesterday around lunch. Patient is not sure if he lost consciousness, states ??I hit my head pretty good, I can?t remember if I was knocked out or not.?? However able to recall events leading up, event and all events afterwards clearly. Complaining of head pain, neck pain, back pain, arm pain and finger pain.? and ?Multiple bruises present. One above right eyebrow, several on right side of body. Hypertensive in triage. 9/10 pain all over. Left proximal arm has deformity present. Moaning throughout triage.? The resident received morphine and fentanyl while in the emergency room. 2. Resident 4?s aforementioned visit to the emergency room was not reported to the regional licensing office and staff 4 confirmed this was accurate.
Plan of Correction:	Facility staff to be educated on incident reporting policy to Administrator. Administrator to ensure incidents are reported to the Regional Licensing Office.
Standard #:	22VAC40-73-210-B
Description:	Based on staff record review and staff interview, the facility failed to ensure all direct care staff attended at least 18 hours of annual training. EVIDENCE: 1. The record for staff 2, date of hire 02/01/2016, contained documentation that staff 2 only had 2.5 hours of training for the time period of 02/01/2021 through 01/31/2022. 2. Interview with staff 4 confirmed this was accurate.
Plan of Correction:	Facility to ensure all direct care staff provide proof of 18 hours of annual training for their facility file records.
Standard #:	22VAC40-73-210-D
Description:	Based on staff record review and staff interview, the facility failed to ensure a registered medication aide (RMA) had the continuing education required by the Virginia Board of Nursing. EVIDENCE: 1. The Virginia Board of Nursing, 18VAC90-60-100, indicates the following: ?B. Continuing education required for renewal. 1. In addition to hours of continuing education in direct care required for employment in an assisted living facility, a medication aide shall have the following: a. Four hours each year of population-specific training in medication administration in the assisted living facility in which the aide is employed; or b. A refresher course in medication administration offered by an approved program.? 2. The record for staff 2, date of hire 02/01/2016, did not contain documentation of the staff member having the required annual 4 hour refresher for the training year 02/01/2021 through 01/31/2022. 3. Interview with staff 4 confirmed this was accurate.
Plan of Correction:	Facility to ensure all RMA staff provide an annual copy of their 4 hour refresher course certificate in medication administration.
Standard #:	22VAC40-73-210-F
Description:	Based on staff record review and staff interview, the facility failed to ensure that the required hours of annual staff training focused on at least two hours of infection control and prevention and at least four hours of mental impairment. EVIDENCE: 1. The record for staff 2, date of hire 02/01/2016, did not contain documentation of the staff member having any infection control and prevention training nor any training that focused on mental impairments for the training year of 02/01/2021 through 01/31/2022. 2. Interview with staff 4 confirmed this was accurate.
Plan of Correction:	Facility to ensure all staff are provided with annual training focused on infection control and at least 4 hours of mental impairment.
Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility shall submit the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. EVIDENCE: 1. The record for staff 1, hired 05/02/2022, did not contain the results of a TB assessment. 2. The record for staff 2, hired 02/01/2016, contained the most recent TB assessment results dated 05/20/2019. 3. Interview with staff 4 indicated that a TB risk assessment did not exist for staff 1 and that there was no current TB assessment for staff 2.
Plan of Correction:	Facility to ensure all staff provide TB screen assessments for their files on an annual basis.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment. EVIDENCE: 1. The staff information sheet provided by staff 4 on the date of inspection indicated that staff 3, hired 09/10/2021, is employed as a housekeeper and direct care staff member. The record for staff 3 contained verification of having completed direct care training; however, the record did not contain verification that staff 3 has obtained first aid certification. 2. Interview with staff 4 indicated that staff 3 does not have first aid certification.
Plan of Correction:	Facility to ensure all direct care staff have their first aid certification.
Standard #:	22VAC40-73-270-4
Description:	Based on staff record review and staff interview, the facility failed to ensure that direct care staff shall be trained in methods of dealing with residents who have a history of aggressive behaviors or of dangerously agitated states prior to being involved in the care of such residents. This includes an annual refresher training for all direct care staff when aggressive residents are in care. EVIDENCE: 1. The record for staff 1, date of hire 05/02/2022, did not contain documentation of aggressive training prior to being involved in the care of such residents. 2. The record for staff 2, date of hire 02/01/2016, did not contain documentation of annual aggressive training for the time period of 02/01/2021 through 01/31/2022. 3. The record for staff 3, date of hire 09/10/2021, did not contain documentation of aggressive training prior to being involved in the care of such residents. 4. Interview with staff 4 confirmed this was accurate.
Plan of Correction:	Administrator to ensure all staff receive necessary training on an annual basis, including aggressive training.
Standard #:	22VAC40-73-320-B
Description:	Based on resident record review and staff interview, the facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually on each resident. EVIDENCE: 1. The most recent report of TB screening for resident 5 was dated 12/04/2020. 2. Interview with staff 4 indicated that this was accurate.
Plan of Correction:	Facility to continue assisting residents in maintaining up to date health assessments. Facility will ensure all residents are provided an assessment for TB on an annual basis.
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 6 was admitted to the facility on 10/29/2021. The Virginia State Police sex offender registry search was not completed until 12/17/2021.
Plan of Correction:	Administrator to ensure The Virginia State Police Sex Offender registry is completed on all prospective admissions prior to their moving into the facility.
Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to ensure that resident personal and social data information was completed as required. EVIDENCE: The ?Resident ? Personal/Social Data? document for resident 6, admission date 10/29/2021, did not include the following information: birth place, personal physician, local department of social services (if applicable), other agency (if applicable), current behavioral and social functioning, strengths and problems.
Plan of Correction:	Administrator to ensure all admissions documentations are completed thoroughly and accurately at the time of admission.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review, the facility failed to ensure an individualized service plan (ISP) was signed and dated by the resident or his legal representative. EVIDENCE: The ISP for resident 4 has been reviewed and updated by the facility on 03/15/2022 and 06/22/2022; however, the ISP was last signed by the resident on 06/07/2021.
Plan of Correction:	Administrator to ensure all ISP?s are signed by residents or their representative.
Standard #:	22VAC40-73-680-D
Description:	Based on observation, the facility failed to ensure that medications shall be administered in accordance with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. The Virginia Board of Nursing (BON) Medication Aide Curriculum, dated 5/21/2013, Chapter 1.3 Section B states that the persons listed on the Virginia BON Medication Aide Registry must comply with the regulations of the board. Further, the Virginia BON Regulations Governing the Registration of Medication Aides (RMA), dated 02/06/2020, 18VAC-90-60-20-A state ?Any person regulated by this chapter shall, while on duty, wear identification that is clearly visible to the client and that indicates the appropriate title issued to such person by the board under which the person is practicing in that setting?. 2. On the date of inspection, at approximately 11:30 AM, LI observed that the RMA on duty was staff 1. While staff 1 was preparing medications for the lunchtime medication pass, LI observed that she was not wearing a nametag. 3. Interview with staff 1 and staff 4 indicated that they typically do not wear nametags since they are a small facility.
Plan of Correction:	Facility to ensure all staff are properly identified by wearing a name badge during their shift.
Standard #:	22VAC40-73-680-I
Description:	Based on record review, the facility failed to ensure that the Medication Administration Record (MAR) shall include the date and time given and initials of direct care staff administering the medication. EVIDENCE: 1. The June 2022 and July 2022 MARs for resident 1 did not contain the date, time, and initials of direct care staff administering medication on multiple dates and times. 2. The June 2022 MAR for resident 4 did not include the date, time given and initial of the staff that administered the resident?s medications for multiple dates during June 2022.
Plan of Correction:	Facility recently converted to new EMAR system which caused inaccuracies in documentation; Administrator to ensure all staff administering medication are properly trained in usage of EMAR system. All staff administering medication are to ensure all medications administered are properly documented.
Standard #:	22VAC40-73-950-E
Description:	Based on record review, the facility failed to implement a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual?s respective responsibilities. The review shall be documented by signing and dating. EVIDENCE: The semi-annual Emergency Preparedness Review, dated 07/02/2022, contained three out of nine staff signatures. There were check marks next to 13 of 23 resident names; however, there were no resident signatures.
Plan of Correction:	Administrator to ensure all residents, staff and volunteers are present for Emergency Preparedness on a semi-annual basis. Signatures to be obtained for all individuals present.
Standard #:	22VAC40-73-990-B
Description:	Based on document review and staff interview, the facility failed to ensure the semi-annual review of the plan for resident emergencies was signed and dated by each staff person. EVIDENCE: 1. The document ?Six Month Resident Emergency Practice? sign-in sheet, dated 07/11/2022, did not contain signatures of any staff that participated in the review on this date. 2. Interview with staff 4 revealed that the practice was completed; however, staff did not sign the sign-in sheet.
Plan of Correction:	Administrator to ensure signatures are obtained by all staff personnel participating in Six Month Resident Emergency Practice.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to ensure that a criminal history record report was obtained on or prior to the 30th day of employment for each employee. EVIDENCE: The record for staff 3, date of hire 09/10/2021, contained documentation that a criminal record history report was not obtained until 06/28/2022.
Plan of Correction:	Administrator to ensure all staff receive criminal history record check within 30 days of hire.