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: May 22, 2024

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: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/22/2024 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 #:	22VAC40-73-640-A
Description:	Based on record review and observation, the facility failed to implement a portion of its medication management plan, specifically regarding methods for monitoring medication administration and the effective use of medication administration records (MARs) for documentation. EVIDENCE: 1. The facility?s current medication management plan that was last updated on 08/01/2022, under PREPARATION AND ADMINISTRATION, states ?A written paper MAR will be written clearly and legibly?. The same medication management plan, under PREPARATION OF MEDICATIONS FOR ADMINISTRATION, regarding administered medications, states ?Every administration will be recorded immediately on the resident?s EMAR? and the medication administration record will be ?initialed by the person administering the medication?. 2. The record for resident 3 contained prescribed orders for TRAMADOL HCL 50 MG TAB ? ?Take 1 tablet by mouth twice daily?. 3. The corresponding controlled drug narcotic administration written record indicated 9 pills in the inventory for this medication; however, the actual pill card for this same medication contained 8 pills. 4. This LI inquired to staff 1 as to the reason for the discrepancy in the narcotic medication administration written record and the actual pills in the card, and staff 1 revealed that she had forgotten to sign the narcotic medication administration written record when she administered the TRAMADOL 50 MG TAB to resident 3 at 08:00 AM on the morning of inspection (05/22/2024).
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-660-A
Description:	Based on observation and staff interview, the facility failed to ensure that a medicine cabinet, container, or compartment that is used for storage of facility-administered medications and dietary supplements prescribed for residents is locked and the individual responsible for medication administration shall keep the keys to the storage area on his/her person. EVIDENCE: 1. During the medication pass observation on 05/22/2024, the date of inspection, at approximately 09:30 AM, this LI observed staff 1 in the hallway preparing medications to administer to resident 4 in his room. After all scheduled medications for resident 4 were dispensed into the medication cup, staff 1 entered the room for resident 4 as this LI was finishing taking notes. As this LI looked up from notes, it was observed that the medication cart that was used to prepare the medications for resident 4 was left unlocked when staff 1 entered his room. This LI pressed in the lock to secure the cart before entering resident 4?s room to observe the medication pass. Upon exiting the resident?s room, this LI informed staff 1 that she had left the medication cart unlocked when she walked away. Staff 1 indicated that she thought she had locked it before she left. 2. While staff 1 finished administering medications on the rest of the same hall, this LI returned to the nurse?s station area on the same floor to perform medication cart audits of the two carts that were stationary at that location. As this LI approached the medication cart that is designated for rooms 526-540, this LI observed the keys laying on top of that cart in the plastic basket and that the cart was unlocked; therefore, this LI began the audit for that cart. While performing that audit, staff 1 returned with the third medication cart and this LI informed her that when this LI approached it, the keys were laying on top of the cart that is designated for rooms 526-540 and that it was unlocked.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation, staff interview, and the regulations for GENERAL PROCEDURES AND INFORMATION FOR LICENSURE, the facility failed to ensure that the findings of the most recent facility inspection were posted on the premises. EVIDENCE: 1. While performing the physical plant observation on the date of inspection, this LI observed that the yellow Acknowledgment of Inspection form, dated 06/14/2023, was posted in a clear plastic sleeve in the common area outside of the dining room; however, the actual results (violations) of that inspection were not posted. 2. The interview at that time with staff 4 did not result in locating the posted results of the 06/14/2023 inspection within the facility.
Plan of Correction:	Not available online. Contact Inspector for more information.