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 20, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

A renewal inspection was initiated on 7/20/2021 and concluded on 7/23/2021. 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 remote documentation review portion of 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 healthcare oversight, fire and emergency drills, health department inspection, and dietician oversight submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 7/22/2021. An exit interview was conducted with the administrator after the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. 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 #:	22VAC40-73-440-D
Description:	440-D Based on record review, the facility failed to ensure that for private pay individuals, the uniform assessment instrument (UAI) is completed as required. EVIDENCE: 1. The UAI for resident 2, dated 4/8/21, stated that the resident needs mechanical help only for bathing; however, the individualized service plan (ISP) for resident 2, dated 4/8/21 stated that the resident needs human supervision and physical assistance, as needed, for bathing. 2. An interview with staff 6 indicated that the ISP is correct. 3. The UAI for resident 2, dated 4/8/21, stated that the resident needs mechanical help and human supervision for stairclimbing; however, the ISP for resident 2, dated 4/8/21, stated that the resident needs physical assistance for stairclimbing. 4. An interview with staff 6 indicated that the ISP is correct. 5. The UAI for resident 2, dated 4/8/21, stated that no help is needed for wheeling; however, the ISP, dated 4/8/21, stated physical assistance is needed for wheeling. 6. An interview with staff 6 indicated that the ISP is correct.
Plan of Correction:	- The administrator or assigned designee will ensure residents UAI and ISP are accurate and updated accordingly. - Administrator or assigned designee will ensure ISP and UAI reflect the same level of function and goals will be established based on each resident?s need - The facility will ensure residents ISP are updated accordingly as changes are indicated.
Standard #:	22VAC40-73-640-A
Description:	640-A Based on documentation review, the facility failed to implement their medication management plan regarding methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility?s current medication management plan states that ?a narcotic count sheet will be maintained for all narcotic medications? and ?when a narcotic is received in the community, it is counted by two staff members and added to the narcotic sheet with the current medication count reflected in the amount on-hand?. 2. The controlled substance log for resident 4 contained documentation for the administration of one Oxycodone 5 mg tab by mouth every six hours as needed (PRN). During the on-site inspection on 7/21/2021, the most recent log entry indicated a count of 49 tablets on 7/19/2021; however, the on-hand count during the on-site inspection was 35 tablets. 3. Interview with staff 6 indicated that the medication staff failed to accurately document this controlled substance for resident 4 between 7/19/2021 and 7/21/2021.
Plan of Correction:	- Administrator will review and educate RMA?s on the facilities medication management plan for documentation of narcotics. - Staff will ensure proper documentation of narcotic distribution to include both the MAR and the facility Narcotic Count Sheet.
Standard #:	22VAC40-73-700-1
Description:	700-1 Based on record review, the facility failed to ensure that valid physician or other prescriber?s orders were obtained for oxygen therapy. EVIDENCE: 1. Physician progress notes for resident 2 indicated that he uses two liters of oxygen at night and as needed; however, there were no physician?s orders for oxygen therapy provided. 2. Interview with staff 6 indicated that resident 2 was on oxygen therapy at his previous assisted living facility; however, there are no physician?s orders for his continued oxygen usage.
Plan of Correction:	- The facility will ensure physician orders are received prior to admission into facility for all DME?s including oxygen.
Standard #:	22VAC40-73-970-A
Description:	970-A Based on documentation review, the facility failed to ensure that fire and emergency drills are completed for each shift in a quarter. EVIDENCE: 1. For the most recent quarter of 2021, fire and emergency evacuation drills were documented to have occurred during first shift on 4/6/21, during first shift on 5/15/21, and during second shift on 6/10/21.
Plan of Correction:	- Administrator or designated staff will ensure fire and emergency drills are conducted quarterly for all three shifts.