VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Meadow Hills Assisted Living Facility
5046 Williamson Road
Roanoke, VA 24012
(540) 467-3180

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

Inspection Date: July 22, 2020

Complaint Related: No

Areas Reviewed:

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

Technical Assistance:

270, 325-B, 440-E, 450-C, 550-F

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 7/22/2020 and concluded on 7/27/2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 21. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, the Sworn Disclosure Statement and Criminal 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 #:	22VAC40-73-70-A
Description:	70-A Based on record review, the facility failed to ensure that any major incident that has negatively affected or that threatens the life, health, safety, or welfare or any resident is reported to the regional licensing office within 24 hours. EVIDENCE: 1. The record for resident 3 contained a Facility Reported Incident (FRI) form which indicated that staff found the resident in an unconscious state after falling out of his chair in the facility dining room on 5/20/2020. 2. The record for resident 3 contained a FRI form which indicated that staff found the resident in an unconscious state after falling in his room on 6/15/2020. 3. Neither of the FRI reports were reported to the regional licensing office.
Plan of Correction:	In such case the facility reported both incidents to the Veteran Administration (as this resident is under their care) however failed to also report it to the Regional licensing office. Facility administrator to ensure all incidents that negatively affected or threatened the life, health, safety, or welfare of a resident is reported to the regional licensing office within 24 hours of such incident.
Standard #:	22VAC40-73-250-C
Description:	250-C Based on record review, the facility failed to ensure that all required personal and social data was maintained and included in the staff record. EVIDENCE: 1. The record for staff 3 did not contain documentation which indicated that she was authorized by the Virginia Board of Nursing to practice as a medication aide on a provisional basis.
Plan of Correction:	Facility administrator and designated personnel is to ensure all staff records are maintained up to date with all necessary documentation.
Standard #:	22VAC40-73-320-A
Description:	320-A Based on record review, the facility failed to ensure that the physical examination report, contained all required items. EVIDENCE: 1. The physical examination report for resident 3, dated 10/8/2019, did not contain a description of the resident?s allergic reactions.
Plan of Correction:	Facility administrator or designated personnel to ensure all areas of the physical examination report is adequately completed by the patient?s physician prior to admission into the facility.
Standard #:	22VAC40-73-450-C
Description:	450-C Based on record review, the facility failed to ensure that the ISP accurately reflected the identified needs of the resident. EVIDENCE: 1. The ISP, dated 7/1/2020, stated that resident 1 requires an ADA Regular Diet; however, the physical examination form, dated 6/1/2020, lists a Heart Healthy Diet. 2. Per interview with staff 4, the ISP does not accurately reflect the dietary needs of the resident. 3. Per interview with staff 4, the diet list in the facility kitchen preparation area does correctly reflect the resident?s diet of Heart Healthy.
Plan of Correction:	Facility administrator or designated personnel to ensure ISP is reflective of most up to date dietary needs.
Standard #:	22VAC40-73-450-F
Description:	450-F Based on record review, the facility failed to ensure that the individualized service plan (ISP) shall be reviewed and updated as the condition of the resident changes. EVIDENCE: 1. The nursing notes, dated 6/22/2020, indicated that the Occupational Therapist (OT) requests that Resident 3 keep his back brace on, and resident 3 should take sponge baths, which are to be supervised by staff. Further, if the resident insists on taking a shower, he needs to have staff to assist him with removing and replacing his back brace before and after the shower process. 2. Per interview with staff 4, this change will last longer than 30 days. 3. The ISP, dated 6/17/2020, was not updated to reflect the requests from OT for the back brace and bathing changes.
Plan of Correction:	Patient?s need for back brace was listed on the ISP. Facility administrator or designated personnel to ensure patient?s ISP is reflective of therapy recommendations as well.
Standard #:	22VAC40-73-480-E
Description:	480-E Based on record review, the facility failed to ensure that the physician?s or other prescriber?s orders, services provided, evaluations of progress, and other pertinent information regarding the rehabilitative services shall be recorded in the resident?s record. EVIDENCE: 1. The hospital physician?s discharge notes, dated 6/16/2020, indicated that home health would come and do a physical therapy/occupational therapy (PT/OT) reassessment on resident 3 on 6/19/2020. 2. The ISP, dated 6/17/2020, indicated that resident 3 will receive home health services by Kindred Home Health. 3. The nurse?s notes, dated 6/22/2020, indicated that a request was made by OT for resident 3 to wear his back brace regularly and to modify his bathing routine due to his back brace; however, evaluations or other pertinent information regarding the rehabilitation services were not found in the record. 4. Per interview with staff 4, therapy notes are sent to the VA which is why there were not any filed in the record for resident 3.
Plan of Correction:	Facility administrator and designated personnel to ensure records from home health services are kept in residents files within the facility.
Standard #:	22VAC40-73-680-I
Description:	680-I Based on record review, the facility failed to ensure that the medication administration record (MAR) shall include the diagnosis, condition, or specific indications for administering the drug or supplement. EVIDENCE: 1. The MAR for resident 1 contained the following medications with no diagnosis: Antacid 500 mg chew tablet, Azelastine 0.1% nasal spray, Docusate 100 mg soft gel, Metformin 500 mg tablet, Polyethylene glycol 3350 238 gm, Spiriva Handihaler 18 mcg cp-Handihaler, Thera tablet, Novolog Flexpen SYR 100U/ML. 2. The MAR for resident 2 contained the following medications with no diagnosis: Novolog 100U, Poly-Iron 150 mg capsule, Lantus 100U/ML vial 10 ML, Loperamide 2 MG capsule, Naloxone 4 MG nasal spray kit. 3. The MAR for resident 3 contained the following medications with no diagnosis: Baclofen 10 MG, Fluticasone Prop 50 MCG spray, Pantoprazole 40 MG tablet.
Plan of Correction:	Facility designated personnel to ensure each resident medication has a noted diagnosis.