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:

Complaint Related: No

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.