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 18, 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 22VAC40-90 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: 07/18/2023 from 09:00 AM until 02:30 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 #:	22VAC40-73-40-B-12
Description:	Based on staff interview, the facility failed to ensure that at all times the department?s representative is afforded reasonable opportunity to inspect all of the facility?s books and records. EVIDENCE: On the date of inspection, LI and collateral 1 were unable to access the following: The entire record of a resident who had recently been discharged, all staff records, health care and dietary oversight reviews, fire and health inspection reports, documentation of the practice/review of plan for resident emergencies, documentation of fire and emergency evacuation drills, and documentation of the review of the facility?s emergency preparedness and response plan because they were locked in an office that was only accessible by a staff member who was not in the facility.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-260-C
Description:	Based on observation, the facility failed to ensure that a listing of all staff who have current certification in first aid or CPR in shall be posted in the facility so that the information is available to staff at all times. EVIDENCE: During the on-site inspection, a staff current first aid and CPR certification list was not found posted in the facility.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-290-A
Description:	Based on observation, the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time. EVIDENCE: During the on-site renewal inspection, a written work schedule which included names and job classifications of all staff working on each shift which indicated who was in charge was not found in the facility.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-290-B
Description:	Based on observation, the facility failed to implement its procedure for posting the name of the current on-site person in charge. EVIDENCE: During the on-site renewal inspection, LI and collateral 1 observed that the bulletin board listed staff 2 as the current manager on duty; however, during the inspection, staff 3 was the current manager on duty.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure that resident physical examinations contained a statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310-H. EVIDENCE: 1. The physical examination for resident 3, dated 10/12/2021, contains documentation on page 2 that the resident requires continuous licensed nursing care, which is a prohibited condition for admission or retention in an assisted living facility. 2. The physical examination for resident 7, dated 11/28/2022, contains documentation on page 2 that the resident requires continuous licensed nursing care, which is a prohibited condition for admission or retention in an assisted living facility.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-390-B
Description:	Based on resident record reviews, the facility failed to ensure that copies of the signed resident agreement/acknowledgement were maintained in the resident?s record. EVIDENCE: 1. The record for residents 1, 2, 3, 5, and 6 did not contain copies of the signed resident agreements. Documentation was noted in resident records that stated, ?Resident agreement in office?. 2. Collateral 1 asked staff 3 if they could provide the signed resident agreement for review. Staff 3 expressed that they were unable to get to the resident agreement as the office is locked and they did not have keys/access to the office.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-B
Description:	Based on resident record reviews, the facility failed to ensure that uniform assessment instruments (UAI) were signed by all required personnel. EVIDENCE: The UAI for resident 3, dated 04/19/2023, had not been signed by the facility administrator on the date of inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record reviews, the facility failed to ensure that individualized service plans (ISP) were reviewed and updated at least once every 12 months. EVIDENCE: The most current ISP in the record for resident 3 was completed on 06/07/2022; however, there were no more recent ISPs for resident 3 available for review on the day of inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-520-I
Description:	Based on observations of the facility?s posted activity schedule, the facility failed to include all required information on the posted activity schedule. EVIDENCE: The activity schedule for July 2023 that was posted in the facility did not contain the hour of the activities that were listed on the schedule.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-550-F
Description:	Based on observation, the facility failed to ensure that the rights and responsibilities of residents shall be printed in 14-point type and posted conspicuously in a public place in all assisted living facilities, including posting the name and telephone number of the appropriate regional licensing supervisor of the Department of Social Services Division of Licensing Programs. EVIDENCE: While performing a walk-through of the facility on the date of inspection, LI did not observe a posting of all resident rights and responsibilities in 14-point type which also included the appropriate licensing supervisor name and contact information.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-610-B
Description:	Based on observations of the facility?s posted menu, the facility failed to record substitutions on the posted menu. EVIDENCE: 1. During a tour of the facility?s physical plant that was conducted the morning of the inspection, collateral 1 noted that facility?s posted menu indicated that classic chicken salad, peach cottage cheese, steamed broccoli, and mini croissant roll was the lunch meal to be served on 07/18/2023, the day of inspection. 2. At 12:02 PM on the day of inspection, collateral 1 observed that the lunch meal that was served consisted of pizza, tossed salad, and mixed fruit. 3. Collateral 1 observed the posted menu again and noted that the substitutions had not been recorded on the menu.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-640-A
Description:	Based on observation and document review, the facility failed to implement a part of its medication management plan, specifically regarding outdated medications and counts of controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility?s most current medication management plan indicates that expired medication will not be retained in the community and that the administrator or designated staff person inspects containers regularly for expiration dates. 2. While performing a medication cart audit on the date of inspection, LI reviewed a sample of medications and treatments throughout all three carts. In cart # 2 (middle cart), LI observed two pre-packaged pill cards for resident 8. One of those cards contained the 5 PM dose of Gabapentin 300 mg with five pills remaining, which expired on 05/14/2023. The second card contained the 8 PM dose of Gabapentin 300 mg with six pills remaining, which expired 05/14/2023. 3. The facility?s most current medication management plan indicates that (a) when a narcotic is received in the community, it is counted by two staff members and added to the narcotic sheet with the current medication count reflected in the amount on hand. The plan also states that (b) at the end of each shift, the staff member responsible for medication completing his/her shift and the staff member responsible for medications who is starting his/her shift, count all narcotic medications and confirm that the amount on hand matches as it is listed on the Narcotic Count Sheet for each medication. Both staff members will sign a Narcotic Reconciliation Sheet to confirm the accurate count of narcotics on hand, and (d) any discrepancies are immediately reported to the administrator. 4. LI reviewed a sample of narcotic medications for count consistency and noted the following for Lorazepam 0.5 mg ?Take 1 cap P.O. 3x a day? for resident 3: a. The 8 AM Individual Resident?s Controlled Substance Record indicated that there were 0 pills remaining most recently on 07/15/2023; however, the corresponding pill card for 8 AM contained 28 pills. b. The 2 PM Individual Resident?s Controlled Substance Record indicated that there were 26 pills most recently on 07/11/2023; however, the pill card for 12 PM contained 21 pills. c. The 8 PM Individual Resident?s Controlled Substance Record indicated that there were 6 pills remaining most recently on 07/13/2023; however, the corresponding pill card for 8 PM contained 5 pills. 5. LI noted the following for Gabapentin 300 mg ?Take 1 capsule by mouth 2x a day? for resident 5: a. The 8 AM Individual Resident?s Controlled Substance Record indicated that there were 0 pills remaining most recently on 07/15/2023; however, there was no corresponding pill card with the medication. b. The 5 PM Individual Resident?s Controlled Substance Record indicated that there were 17 pills remaining most recently on 07/16/2023; however, the three corresponding pill cards for this 5 PM medication contained 19 pills, 28 pills, and 28 pills. (SEE ADDITIONAL EVIDENCE PAGE)
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-650-F
Description:	Based on resident record review, the facility failed to ensure that whenever a resident is admitted to a hospital for treatment of any condition, the facility shall obtain new orders for all medications and treatments prior to or at the time of the resident's return to the facility. The facility shall ensure that the primary physician is aware of all medication orders and has documented any contact with the physician regarding the new orders. EVIDENCE: 1. The record for resident 5 contained documentation of a hospital discharge summary, dated 04/15/2023, which includes medication changes to start taking Aripiprazole 20mg daily, Dextromethorphan-guaifenesin 1ml every 6 hours as needed, Famotidine 10mg twice a day, Fluticasone Propionate 1 spray to each nostril every day, Melatonin 3 mg every night, Polyethylene Glycol powder 17g daily and to stop taking Gabapentin 300mg, Haloperidol Deconate 100mg and Lisinopril 40mg. 2. The record for resident 5 does not have documentation that the residents primary care physician was made aware of the new medication orders from the 04/15/2023 hospital discharge summary.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-E
Description:	Based on resident record and medication administration record (MAR) review, the facility failed to ensure the recording of all medical procedures. EVIDENCE: The July 2023 MAR for resident 5 has a physician order for blood pressure checks twice a day in the morning and the evening. The MAR does not have staff initials or documentation of the results of the resident?s blood pressure check at 5pm on 07/07/2023 through 07/07/2023 and 07/15/2023 through 07/17/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record and medication administration record (MAR) review, the facility failed to ensure that all required information was included on resident MARs. EVIDENCE: 1. The July 2023 MAR for resident 5 does not have staff initials for the administration of any of the resident?s medications for the entire day on 07/04/2023 and 07/16/2023. The MAR does not have staff initials for the administration of Gabapentin 300mg and Haloperidol 5mg at 5 PM and Famotidine 10mg and Melatonin 3mg at 8 PM on 07/02/2023 through 07/07/20203 and 07/15/2023 through 07/17/2023. 2. The June and July 2023 MARs for resident 2 contained numerous instances of no diagnosis for medications or treatments and numerous instances of no staff initials when medication was administered.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-700-2
Description:	Based on observations of the facility?s physical plant, the facility failed to ensure that a ?No Smoking-Oxygen in Use? sign was posted on all rooms where oxygen is in use. EVIDENCE: 1. During a tour of the facility?s physical plant, an oxygen concentrator was observed sitting by the first bed in room 13. 2. Resident 2, who resides in room 13, expressed that he uses the oxygen at bedtime and when he needs it. 3. The room did not contain a ?No Smoking-Oxygen in Use? sign on the day of inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-750-E
Description:	Based on observations of the facility physical plant, the facility failed to ensure that all residents had clean towels. EVIDENCE: Rooms 13 and 14 were noted to both have two residents residing in each room. The rooms did not have any towels for the residents use as of the day of inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-A
Description:	Based on observations of the facility?s physical plant, the facility failed to maintain the interior of the building in good repair and keep clean. EVIDENCE: 1. The closet doors in room 10 and room 14 were noted to not close properly as the doors will not completely shut into the door frames. 2. Several floor tiles were noted to be cracked in the bathroom floor of room 11 and a wet malodorous substance was noted on the floor. 3. The two vents in the hallway near the nursing station and the posting board were noted to be loose from the ceiling and contained dirt/dust on the grills. 4. The ceiling in the hallway near the posting board was noted to have ceiling cracks/damage and one area where the ceiling is bulging.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-B
Description:	Based on observations of the facility?s physical plant, the facility failed to keep the building from foul, stale, musty odors. EVIDENCE: Room 11 was noted to have a strong foul odor in the room and bathroom on the day of inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-E
Description:	Based on observation and resident interview, the facility failed to ensure that equipment owned by a resident shall be, at a minimum, in safe condition. EVIDENCE: 1. On the date of inspection, LI was speaking with resident 2 who revealed that the hand brakes on the rollator that he uses do not work and have not worked for a while. Resident 2 stated that he uses the rollator frequently while in and out of the facility due to being unsteady when walking and transferring. 2. LI tested the hand brakes of the rollator while pushing it and resident 2 also tested the brakes while LI watched, and both times the brakes did not stop the device from moving.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-920-D
Description:	Based on observation, the facility failed to ensure that grab bars were installed by resident toilets and that stools were available for use in showers. EVIDENCE: 1. The individualized service plan (ISP) for resident 2, dated 04/08/2023, indicated that this resident requires the use of grab bars and a shower chair for bathing. 2. On the date of inspection, LI performed a walk-through of room 13, belonging to resident 2, and observed that the bathroom did not have a shower chair available to resident 2. An interview with resident 2 also revealed that he often has trouble balancing when toileting because there are no grab bars near the toilet.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation, the facility failed to ensure that the findings of the most recent inspection of the facility are posted on the premises of the facility. EVIDENCE: During the on-site inspection, the most recent inspection findings that were posted were from the inspection on 11/03/2022; however, the most recent inspection at the facility prior to the current inspection was on 12/12/2022.
Plan of Correction:	Not available online. Contact Inspector for more information.