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 14, 2023

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 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: 06/14/2023 from 08:30 AM until 02:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 #:	22VAC40-73-660-A-1
Description:	Based on observation, the facility failed to ensure that medications were stored in a locked area. EVIDENCE: On the date of inspection at 08:45 AM, LI and collateral 1 observed an unlocked cart containing medications to be sitting inside of the open conference room that was being utilized for the inspection. There were no staff observed around the cart. Staff 5 was also brought in to observe the unlocked cart.
Plan of Correction:	On day of inspection, a new process was implemented for the overflow med cart to ensure that the oncoming and off going nurse check that the overflow med cart is locked. All nurses were educated on the new process. Clinical Manager will audit periodically for compliance.
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the building, the facility failed to store cleaning supplies and other hazardous materials in a locked area. EVIDENCE: 1. At approximately 9:18AM during on-site inspection, collateral 1 noted that the door to the housekeeping room on the third floor was unlocked and unattended. Collateral 1 noted a container of Diversey tile and grout rejuvenator and a container of Diversey sanitizer located in the bottom of the gray cabinet located in the back corner of the room. 2. At approximately 12:19PM, collateral 1 noted that the door to the housekeeping room on the third floor was still unlocked and unattended and the two aforementioned items were still located in the gray cabinet.
Plan of Correction:	On the day of inspection, it was discovered that the 3rd floor housekeeping closet handle was locked but the door had to be pulled shut forcefully for the door to latch and fully lock. This issue was addressed and corrected on the day of inspection.