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: July 20, 2022

Complaint Related: No

Areas Reviewed:

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

Technical Assistance:

320-A, 550-F, 690

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: 07/20/2022 08:45 AM ? 12:30 PM 07/22/2022 07:45 AM ? 08:30 AM 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 #:	22VAC40-73-210-D
Description:	Based on record review, the facility failed to ensure that annual training for medication aides included continuing education as required by the Virginia Board of Nursing. EVIDENCE: 1. The Regulations Governing the Registration of Medication Aides by Virginia Board of Nursing, section 18VAC90-60-100-B, page 9, state that a medication aide shall have four hours each year of population-specific training in medication administration in the assisted living facility in which the aide is employed; or a refresher course in medication administration offered by an approved program. 2. The records for staff 2, hired 11/06/2019, and staff 3, hired 10/04/2019, did not contain documentation of having completed the required medication administration training since employment began.
Plan of Correction:	The Administrator who is also a Virginia Board of Nursing approved Medication Aide instructor completed a refresher course in Medication Administration for Staff 2 hired on 11/06/2019 and Staff 3 hired 10/04/2019.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure that the comprehensive individualized service plan (ISP) shall include a description of identified needs and date identified based upon the uniform assessment instrument (UAI) as well as other sources. EVIDENCE: The UAI for resident 1, dated 05/11/2022, indicated that the resident requires human physical assistance for dressing and supervision for eating/feeding; however, the ISP for resident 1, dated 05/20/2022, did not address these identified needs.
Plan of Correction:	The Administrator updated the Individualized Service plan dated 05/20/2022 to address the need for resident 1 to be provided human physical assistance with dressing and also staff supervision with eating and feeding. The updated plan signed by resident and administrator as required by state regulations.