VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Magnolia Ridge ALF
1007 Amherst Street, SW
Roanoke, VA 24015
(540) 342-8861

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: May 10, 2022

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: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/10/2022 9:20am until 2:30pm 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: 24 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standards or law, and violations 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 violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-1
Description:	Based on observations made of the facility medication cart and interviews with staff, the facility failed to ensure that blood glucose monitoring practices that are consistent with CDC recommendations were followed when assisted blood glucose monitoring is required. EVIDENCE: 1. An unlabeled glucometer was observed lying on top of the medication cart on the day of inspection. 2. An unlabeled glucometer was observed in the right top drawer on the medication cart. 3. A bag labeled with resident 8?s name was noted in the medication cart. The glucometer inside of the bag was unlabeled. 4. A multi-stick penlet device was observed lying on top of the medication cart on the day of inspection. An interview conducted with staff person 2 on the day of inspection expressed that the facility currently did not have any single use safety lancets for assisted blood glucose monitoring and that the multi-stick penlet lying on top of the medication cart had been used to check blood glucoses for both residents 1 and 2 that morning.
Plan of Correction:	All glucometers were immediately labeled. Separate lancets were used for each of the two residents in the multi-stick penlet. However, staff was re-instructed to use the single use lancets and must obtain or notify facility administrator no less than 1 week of supplies on hand.
Standard #:	22VAC40-73-490-A
Description:	Based on a review of facility documentation, the facility failed to ensure that a health care oversight was completed at least every 3 months for resident who are assessed as assisted living level of care. EVIDENCE: 1. The most recent health care oversight available for review was dated 01/09/2022. The facility houses residents who are assessed at an assisted living level of care which require a healthcare oversight every 3 months.
Plan of Correction:	The healthcare oversight was completed.
Standard #:	22VAC40-73-610-D
Description:	Based on a review of resident records, observations of the mid-day meal and interviews with staff, the facility failed to ensure that diets prescribed for residents by their physician was prepared and served according to physician?s orders. EVIDENCE: 1. The record for resident 2 has documentation of a physician order dated 05/23/2019 for a No Added Sweets diet. 2. The record for resident 3 has documentation of a physician order dated 10/20/2021 for a No Concentrated Sweets diet. 3. The mid-day meal was observed at 12:11pm on the day of inspection in the presence of staff person 5. It was noted that a hamburger with lettuce, tomato and onion, tator tots, and white cake with icing was served to all resident in the dining room including residents 1 and 2. An interview was conducted with staff person 4 on the day of inspection in which it was expressed that the cake that was served during the mid-day meal was a regular cake with icing. The LI asked staff person 4 if a reduced or sugar free desert option was available for residents who have diets requiring No Added Sweets or No Concentrated Sweets. Staff person 4 expressed that there are sugar free deserts available but that they had not been served to residents 2 or 3 at the mid-day meal on the day of inspection.
Plan of Correction:	The facility has clarified residents diets and dietary staff will serve prescribed diets.
Standard #:	22VAC40-73-640-A
Description:	Based on observations made of the facility medication refrigerator, the facility failed to follow their medication management policy in regards to destruction of discontinued medications and medications with expirations dates. EVIDENCE: 1. On the day of inspection 3 Lantus Solostar pens and 1 Novolog Flexpen was observed in the medication refrigerator for resident 3, who had passed away on 02/26/2022. The facility medication management plan has documentation that it is the facility?s best practice to return all expired and discontinued medications to the pharmacy. 2. An open bottle of Lantus insulin was observed in the medication refrigerator for resident 1 on the day of inspection. The bottle did not contain a date that the insulin was opened to ensure that it is discarded within 28 days of opening per manufacturer?s instructions. The facility medication management plan has documentation to check expiration dates before administering monthly and before each med pass.
Plan of Correction:	The medications were discarded according to facility?s medication management plan. Undated medications were discarded according to facility medication management plan. The administrator reviewed/reinforced facility medication management plan with the medication aides.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observations made of the facility medication room and cart. The facility failed to ensure that medication cabinets, containers or compartments were locked. EVIDENCE: 1. At 9:20am on the day of inspections it was observed that the sliding glass window in the door to the facility medication room was unlocked. The LI was able to reach their hand through the window and open the door to the medication room. The room was unoccupied and contained a shelf with numerous medications for multiple residents sitting on the shelf. The facility medication cart, which contained various medications for multiple residents was also stored in this room and was observed to be unlocked.
Plan of Correction:	The importance of locking the med room/cart was strongly reviewed and reinforced by the administrator with staff.
Standard #:	22VAC40-73-660-B
Description:	Based on observations made of the facility?s physical plant and resident record review, the facility failed to ensure that medications kept in residents? rooms were stored in an out of sight place in the residents? rooms and for only residents who have been assessed as capable of self-administering their own medications. EVIDENCE: 1. A bottle of Chlorhexidine Gluconate Mouth Wash was observed sitting out on a dresser in the room for resident 3 on the day of inspection. An interview with resident 3 expressed that he uses this mouth wash himself twice a day. 2. The uniform assessment instrument (UAI) dated 01/09/2022 in the record for resident 3 has documentation that the resident requires medication administration from a layperson. The physician order in resident 3?s record for the Chlorhexidine Gluconate Mouth Wash dated 04/18/2022 does not have instructions that the resident can self-administer this prescribed medication.
Plan of Correction:	The mouthwash was removed from the resident?s room. Staff was instructed that all self-administering medications must have a doctor?s order and meds must be securely kept in resident?s room.
Standard #:	22VAC40-73-680-B
Description:	Based on observations made of the facility medication room and medication cart, the facility failed to ensure that all medications remained in the pharmacy issued container with the prescription label until administered to residents. EVIDENCE: 1. A paper souffle cup with 1 whole and 1 half white pill was observed to be sitting out on the shelf in the medication room. 2. 3 white pills were observed to be lying loose in the bottom of the third drawer of the medication cart.
Plan of Correction:	The medications were discarded according to facility management of medication plan. Plan reviewed with staff.
Standard #:	22VAC40-73-890-B
Description:	Based on observations made of the facility physical plant, the facility failed to ensure that the interior of the building was adequately lighted for the safety and comfort of residents and staff. EVIDENCE: 1. The ceiling lights in the hallway outside of rooms 10, 20, 27, the visitor/employee bathroom and the Administrators office were noted to be inoperable on the day of inspection.
Plan of Correction:	All lights were replaced. Will replace lighting immediately when needed