VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Evergreen Assisted Living Community
1437 Peter's Creek Road, NW
Roanoke, VA 24017
(540) 526-8022

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: June 4, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

The Licensing Inspector and the facility Administrator had a discussion regarding individualized service plans.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 6/4/2020 and concluded on 6/5/2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was five. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed two resident records, two staff records, including the Sworn Disclosure statement and Criminal History Record report for all new staff members, resident roster, staff roster, staff schedule, facility health care oversight, fire and emergency drills, health department inspection, and dietitian oversight submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-320-A
Description:	320-A Based on record review, the facility failed to ensure that the physical examination and report contained any known allergies and a description of the person?s reactions. EVIDENCE 1. The physical examination and report for resident 1, dated 9/3/2019, listed allergies to Benadryl, Gabapentin, Levofloxacin, Morphine Sulfate, Penicillin, and Sulfonamides; however, the report failed to indicate a description of the resident?s allergic reactions to these medications. 2. The physical examination and report for resident 2, dated 9/19/2019, listed allergies to Codeine, Penicillin, and Tramadol; however, the report failed to indicate the description of the resident?s allergic reactions to these medications.
Plan of Correction:	The Administrator shall ensure that all reports of physical examination for residents has allergies listed with description of reactions to such products.
Standard #:	22VAC40-73-650-B
Description:	650-B Based on record review, the facility failed to ensure that physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements, shall include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. EVIDENCE 1. The physician?s orders for resident 1 did not identify a diagnosis, condition, or specific indications for administering each drug. 2. The physician?s orders for resident 2 did not identify a diagnosis, condition, or specific indications for administering each drug.
Plan of Correction:	The Administrator will re-enforce to all HCP who prescribe medications to residents to include diagnosis or indications for use with the order for administering the drug.
Standard #:	22VAC40-73-700-1
Description:	700-A Based on record review, the facility failed to ensure that physician?s orders for oxygen therapy included the oxygen source, such as compressed gas or concentrators, and the delivery device, such as nasal cannula, reservoir nasal cannulas, or an oxygen mask. EVIDENCE 1. The physician?s orders for resident 1, dated 4/15/2020 and 5/27/2020, did not indicate the source of the oxygen to be received. 2. The physician?s orders for resident 1, dated 4/15/2020 and 5/27/2020, did not indicate the type of oxygen delivery device.
Plan of Correction:	The Administrator will ensure that oxygen therapy orders for residents includes the source of the oxygen to be received, and the type of oxygen delivery device.