VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Jeanne's Elderly Care
1682 Monterey Road
Roanoke, VA 24019
(540) 563-1262

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: March 28, 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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 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:

The LI for Jeanne's Elderly Care conducted a monitoring visit at the facility on 03/28/2022 from 9:30am until 1:30pm and noted 7 residents to be in care. A tour of the facility physical plant was conducted and required posting were noted. The morning exercise activity and mid day meal were observed. Medication management was reviewed and the medication cart was audited. Resident and staff records as well as other forms of facility documentation were reviewed and interviews were conducted with residents and staff. An exit interview was conducted with the facility Administrator on the day of inspection in which all violations were discussed and opportunities were given for the facility to provide any additional information. Please respond back to your LI with your plan of correction within 10 days of receipt of this notice. If you have any questions or concerns please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-100-C-1
Description:	Based on a review of the facility infection control program, the facility failed to follow thier infection control plan and include all required elements of this regulation that went into effect with the Standards for Assisting Living Facility in February 2018. EVIDENCE: 1. The facility infection control plan that was reviewed on the day of inspections did not contain all information required by the standard on the day of inspection. 2. An unlabeled glucometer was observed in the medication cart on the day of inspection. The facility infection control plan has documentation that glucometers will be labeled with residents names.
Plan of Correction:	1. The infection control plan will be reviewed and modified so that it will contain all required elements in the standard that went into effect Feb. 2018. 2. The unlabeled glucometer in the medicine cart has been labeled. In the future all glucometers will be labeled as stated in the infection control plan.
Standard #:	22VAC40-73-200-B
Description:	Based on a review of resident records and staff interviews, the facility failed to ensure that direct care staff who are responsible for caring for residents with special health care needs only provided services within the scope of their practice and training. EVIDENCE: 1. The March 2022 medication administration record (MAR) for resident 1 has a physician order dated 3/17/2022 for Triad wound dressing topically to the sacrum daily. Staff person 3's initials are present on the March 2022 for resident 1 from 3/18/2022 through 3/22/2022 as providing this wound care daily. It was noted that staff person 3 is a registered medication aide and this wound care treatment is a service that is outside of their scope of practice.
Plan of Correction:	Any resident with wound care treatments will only have treatments provided by licensed nurse or hospice nurse.
Standard #:	22VAC40-73-320-B
Description:	Based on a review of resident records, the facility faield to ensure that a screening for tuberculosis was completed annually for all residents. EVIDENCE: 1. The record for resident 2 has documentation that the last screening for tuberculosis was completed on 2/19/2021.
Plan of Correction:	The tuberculosis screening for resident 2 was completed on 3/29/2022. In the future tuberculosis screenings will be done annually.
Standard #:	22VAC40-73-450-D
Description:	Based on a review of resident records, the facility failed to ensure that coordinated services to be provided by hospice and by the facility were included on individualized service plans (ISPs). EVIDENCE: 1. The record for resident 1 has documentation that the resident was admitted to hospice services on 1/28/2022. The ISP dated 5/27/2021 has not been updated to reflect the residents needs for hospice or the services that hospice is providing.
Plan of Correction:	The ISP for resident 1 has been updated to include hospice services that are being provided. In the future all ISP's will be updated to include the hospice needs and services when residents require hospice.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of resident records, the facility failed to ensure that individualized service plans were updated when a change in a residents needs occurred. EVIDENCE: 1. The record for resident 1 has documentation that the resident is allergic to Codeine, Erythromycin and Penicillin. A fall risk rating dated 10/18/2021 has documentation that resident 1 is a high risk for falls. A physician order dated 2/8/2022 for oxygen 2 litters/min via nasal cannula PRN and a signed "Do Not Resuscitate" signed 2/2/2022 was noted in resident 1's record. Hospice notes from 2/3/2022 to current have documentation that resident 1 is receiving wound care services. The ISP dated 5/27/2021 in the record for resident 1 has not been updated to reflect any of these identified needs for resident 1. 2. The record for resident 3 has documentation of a physician order dated 9/21/2021 for a no added salt diet and a physician order dated 11/2/2021 for compression stockings. The ISP dated 11/6/2021 in the record for resident 3 has not been updated to reflect these identified needs.
Plan of Correction:	1. The ISP for resident 1 has been updated to reflect all identified needs. In the future all ISP's will show all identified needs and will be updated when needs change. 2. The ISP for resident 3 has been updated to reflect the physicians order for the no added salt diet and for compression stockings.
Standard #:	22VAC40-73-640-A
Description:	Based on a review of the facility infection control program, the facility failed to ensure that their medication management plan contained all required elements of this regulation that went into effect with the Standards for Assisting Living Facility in February 2018. EVIDENCE: 1. The facility medication management plan that was reviewed on the day of inspections did not contain all information required by this standard on the day of inspection. 2. An open and in-use Lantus Solostar and Humalog Kwik Pen was observed in the medication cart for resident 2. The pens were not labeled with an open date to ensure that they were discarded with in 28 days of opening per manufacturers instructions.
Plan of Correction:	1. The medication management plan will be reviewed and revised to include all elements in the standard. 2. Both Lantus Solostar and Humalog Kwikpen have been labeled with an open date. In the future all Lantus Solostar and Humalog Kwikpens will be labeled with an open date to ensure that they are discarded in 28 days per manufacturer instructions.
Standard #:	22VAC40-73-640-D
Description:	Based on a review of facility reference materials, the facility failed to ensure that their medication reference book was no more than two years old. EVIDENCE: 1. The facility medications reference book that was located in the facility medication cart was noted to be dated from 2018.
Plan of Correction:	A new medication reference book has been purchased and placed in the medication cart. The facility will purchase a new medication reference book every 2 years.
Standard #:	22VAC40-73-650-E
Description:	Based on a review of resident records, the facility failed to ensure that a resident record contained a physician order. EVIDENCE: 1. The record for resident 1 has a hospice noted dated 3/22/2022 that states the residents wound care was changed from triad to Bag Balm for wound care. The record for resident 1 does not contain a physician order for the change in the residents wound care treatment.
Plan of Correction:	The facility will make sure that we have all physician orders for residents. The facility will alos make sure that hospice gives all physician orders for residents.
Standard #:	22VAC40-73-680-D
Description:	Based on a review of resident records and medication administration records (MARs), the facility failed to ensure that all medications were administered in accordance with physician instructions. EVIDENCE: 1. The March 2022 MAR for resident 2 has a physician order for Humalog Kwikpen to be administered 3 times a day per a sliding scale 151-199-2 units; 200-249-4 units; 250-299- 6 units; 300-349- 8 units and 350-399- 10 units. The MAR has documentation 4pm of the resident blood sugar being 157 on 3/18/2022, 151 on 3/20/2022 and 166 on 3/24/2022 but there is no documentation that the sliding scale insulin dosage was administered for the blood sugars.
Plan of Correction:	In the future the medication aide or nurse will administer the Humalog Kwikpen according to physician order.
Standard #:	22VAC40-73-690-B
Description:	Based on a review of resident records, the facility failed to ensure that a medication review was completed every six months. EVIDENCE: 1. The record for residents 1, 2 and 3 do not have documentation that a medication review has been complete since 8/13/2021.
Plan of Correction:	A medication review will be completed for each resident every 6 months.
Standard #:	22VAC40-73-700-2
Description:	Based on observations made of the facility physical plant, the facility failed to post a "No Smoking-Oxygen in Use" sign by any room where oxygen is in use. EVIDENCE: 1. An oxygen concentrator was observed sitting out by the bed closest to the window in room 1. A oxygen tank was also noted sitting in the closet in room 1. The room did not have a "No Smoking-Oxygen in Use" sign posted on the day of inspection.
Plan of Correction:	A oxygen in use sign was posted on the bedroom door for resident 1 while inspector was still at facility. In the future the facility will ensure that oxygen in use signs are not just placed on the outside doors but also posted on the door to room where oxygen is in use.
Standard #:	22VAC40-73-860-G
Description:	Based on observations made of the facility physical plant, the facility failed to maintain hot water temperatures between 105'F to 120'F. EVIDENCE: 1. The hot water from both bathrooms in the facility was noted to be 99.8'F on the day of inspection.
Plan of Correction:	The hot water heater is being replaced. This has been contracted out by a local plumbing company. They have came out to the facility and inspected the hot water heater and have replaced the thermostat until hot water heater is installed.