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: July 13, 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 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

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: 07/13/2023 8:30AM until 3:30PM 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: 14 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: morning medication pass, part of breakfast and the noon-time meal, audit of the facility?s medication cart 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 #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure that an individualized service plan (ISP) contained all required components. EVIDENCE: The record for resident 5 contains documentation from the Virginia State Police that the resident is a registered sex offender; however, this information is not included on the resident?s ISP dated 10/12/2022.
Plan of Correction:	Was not listed in reg book. Administrator will place on ISP
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and staff interview, the facility failed to ensure medications were administered in accordance with physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 2 contains a physician?s order, dated 06/01/2023, for Levothyroxine Sodium 50MCG one tablet by mouth every day before breakfast for hypothyroid. 2. During on-site inspection while the licensing inspector (LI) and Collateral 1 were observing the morning medication pass being conducted by staff 2, the LI observed staff 2 preparing medications for resident 2 which include Levothyroxine Sodium 50MCG. The LI asked staff 2 when she was finished pouring the medications, and prior to her administering the resident?s medications, if the resident had eaten breakfast or not because the LI had overheard the resident talking about what he had eaten for breakfast that morning. Staff 2 proceeded to ask a kitchen staff member and staff 4 if the resident had eaten breakfast and it was verified by both the staff that the resident had already eaten breakfast. Staff 2 confirmed that she had not given the resident Levothyroxine prior to the resident eating breakfast and the medication was not administered. This was also noted by staff 4 and Collateral 1. 3. The record for resident 2 contained a physician?s order, dated 06/01/2023, for Metoprolol Tartarate 25 MG take one-half tablet by mouth twice daily for heart health and blood pressure and to hold the medication if the resident?s systolic blood pressure (SBP) is less than 100 and diastolic blood pressure (DBP) is less than 60. 4. The June 2023 medication administration record (MAR) for resident 2 indicates that Metoprolol Tartarate was administered to the resident at 9:00PM on 06/29/2023 and the July 2023 MAR for the resident indicates that Metoprolol Tartarate was administered to the resident at 9:00PM on 07/06/2023; however, the June and July 2023 MARs did not contain blood pressure readings for these dates and times and the 06/29/2023 and 07/06/2023 24 hour shift report documents provided by staff 4 did not include blood pressure readings at 9:00PM for either day. Interview with staff 4 confirmed that this was accurate. In addition, the June 2023 MAR for resident 2 indicates that on 06/25/2023 at 9:00PM Metoprolol Tartarate was withheld per doctor?s orders; however, the resident?s documented blood pressure was 166/54 and should have been administered per the physician?s order.
Plan of Correction:	Facility has a new pharmacy and the QMAR system will not allow to go further until medication corrected. Facility will have management and charge nurse and RMA audit QMAR daily. Facility had a temp working and did not remember circling the medication. Manager has in-serviced and manager will monitor.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to ensure that medication administration records (MARs) contained all required components. EVIDENCE: 1. The July 2023 MAR for resident 2 did not include the date, time given and initials of staff administering the following medications on 07/08/2023 for the resident: scheduled 5:00PM Docusate Sodium 100MG softgel, Senna 8.6MG tablet, Wixela inhaler, 2. The July 2023 MAR for resident 5 did not include the date, time given and initials of staff administering the following medications on 07/08/2023 for the resident: scheduled 5:00PM Benztropine Mesylate 1MG tablet, Buspirone HCL 5mg tablet, Ziprasidone 40MG capsule, and Lamotrigine 100MG tablet.
Plan of Correction:	Corrected. Facility has a new pharmacy and the QMAR system will not allow to go further until medication corrected. Facility will have management and charge nurse and RMA audit QMAR daily.