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: May 6, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/06/2022 09:15 AM ? 12:30 PM 06/24/2022 09:30 AM ? 11:00 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/21/2022 regarding allegations in the area(s) of: Building and grounds conditions, staffing levels, management of resident funds, and resident care. Number of residents present at the facility at the beginning of the inspection: 23 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-390-A
Complaint related:	No
Description:	Based on record review, the facility failed to ensure that the written agreement shall include a listing of specific charges for accommodations, services, and care to be provided to the individual resident signing the agreement, the frequency of payment, and any rules relating to nonpayment; the requirements or rules to be imposed regarding resident conduct and other restrictions or special conditions; those actions, circumstances, or conditions that would result or might result in the resident?s discharge from the facility. EVIDENCE: The resident agreement for resident 1, dated 04/08/2021, did not indicate the monthly fee that would be charged to the resident for the care and services provided, nor did it indicate the requirements or rules to be imposed regarding resident conduct and other restrictions or special conditions and those actions, circumstances, or conditions that would result or might result in the resident?s discharge from the facility.
Plan of Correction:	Administrator to audit all Resident written agreement and ensure all include listing for specific charges for accommodations, services, and care to be provided to the individual resident signing the agreement, the frequency of payment, and any rules relating to nonpayment; the requirements or rules to be imposed regarding resident conduct and other restrictions or special conditions; those actions, circumstances, or conditions that would result or might result in the resident?s discharge from the facility. 2. Residents written agreements will be updated as needed with new dated signatures obtained from Residents and/or Responsible Party as indicated.
Standard #:	22VAC40-73-450-H
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that the care and services specified in the individualized service plan (ISP) are provided to each resident. EVIDENCE: 1. The ISP for resident 1, dated 04/8/2022, contained an identified need for the resident?s use of durable medical equipment (DME) which included a rollator, grab bars, shower chair, and cane. 2. For this identified need, the ISP stated ?staff will assist the resident with maintenance/repair/use of DME equipment as needed through observation, prompting, and physical assistance?. 3. While interviewing resident 1 on the date of inspection, collateral 1 observed and tested his rollator and found that the rollator did not stop when brake handles were squeezed. 4. The condition of the rollator for resident 1 was brought to the attention of staff 1 who was unaware.
Plan of Correction:	1. Prior to 4/8/2022, facility was assisting Resident 1 in obtaining new Rollator as ordered by his physician. Facility contacted several DME companies and was unable to secure a new Rollator for Resident 1 as resident was not in ?window? for a new Rollator according to Resident 1 insurance company. - Resident 1 received donated Rollator by outside entity prior to 4/8/2022. At that time Rollator was in good working order - Since Collateral 1 inspection of 4/8/2022, Facility provided Resident 1 with loaner Rollator until insurance company will pay for new equipment. 2. Facility will continue to assist residents in maintaining good working DME equipment as needed.
Standard #:	22VAC40-73-560-I
Complaint related:	No
Description:	Based on record review, the facility failed to ensure that a current picture of each resident shall be readily available for identification purposes or, if the resident refuses to consent to a picture, there shall be a narrative physical description, which is annually updated, maintained in the resident?s file. EVIDENCE: The record for resident 1, admitted 04/08/2021, did not contain a current picture nor a narrative physical description.
Plan of Correction:	1. Administrator to audit resident charts and ensure each resident have an updated photo. 2. Facility to update resident?s photos on an annual basis.
Standard #:	22VAC40-73-580-E
Complaint related:	Yes
Description:	Based on record review and staff interview, the facility failed to develop and implement a policy to monitor each resident for warning signs of changes in physical or mental status related to nutrition; and compliance with any needs determined by the resident?s ISP or prescribed by a physician or other prescriber, nutritionist, or health care professional. EVIDENCE: 1. The record for resident 1, admitted 04/08/2021, contained a facility progress report to the resident?s doctor, dated 11/19/2021, which indicated that the reason for his doctor?s visit was for ?hematuria, diabetes, and weight loss?. 2. Regarding the weight loss, the same progress report also contained a signed doctor?s progress report, dated 11/19/2021, which indicated and ordered that the resident was evaluated as having ?abnormal weight loss ? Rx Glucerna shakes bid?. 3. An interview by collateral 1 and LI with staff 1 on 05/06/2022, determined that the facility has not developed or implemented a policy to monitor residents for warning signs of changes in physical or mental status related to nutrition and to ensure compliance with any needs determined by the resident?s ISP or prescribed by a physician or other prescriber, nutritionist, or health care professional.
Plan of Correction:	Facility Administrator to review with all staff facility policy on monitoring and reporting residents for warning signs of changes in physical or mental status related to nutrition. -Facility staff to notify residents physician or other prescriber, nutritionist, or health care professional within 24 hours of noted nutritional changes. - Facility staff to document reports of said warning signs accordingly in residents file.
Standard #:	22VAC40-73-650-A
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. EVIDENCE: 1. On the first date of inspection, 05/06/2022, the record for resident 1 contained signed physician?s orders dated 11/19/2021 which indicate to ?start Glucerna 1 bottle bid? for abnormal weight loss. 2. Collateral 1 and LI reviewed the May 2022 Medication Administration Record (MAR) for resident 1 to ensure that the resident was receiving Glucerna as ordered; however, the Glucerna was not found on the MAR. 3. Collateral 1 and LI interviewed staff 1 about the Glucerna and staff 1 indicated that the Glucerna is not available in the facility for the resident as the facility was unaware of the orders dated 11/19/2021. 4. At a subsequent inspection on 06/24/2022, LI reviewed current physician?s orders and June 2022 MAR for resident 1, neither of which listed the Glucerna. 5. Interview with staff 1 indicated that the facility still does not have the Glucerna for resident 1. 6. The record for resident 1 did not contain physician orders to discontinue the Glucerna, and discontinue orders were not on file at the facility.
Plan of Correction:	1. Attempts made by facility to obtain Glucerna as ordered by physician following 5/6/2022 inspection failed as Resident 1 insurance carrier did not cover Glucerna 2. Facility scheduled Resident 1 for follow-up PCP appointment, with Resident seeing PCP on 6/24/2022. After discussion with PCP and Pharmacy, new orders received 6/29/2022 for Resident 1 to receive Ensure BID. 3. Facility to ensure supplement orders are on MARs as ordered by PCP or Healthcare provider.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on observation during a tour of the physical plant, resident record review and staff interview, the facility failed to ensure medications were administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. The individualized service plan (ISP) for resident 2 with a review date of 10/26/2021, indicated the following for medication management, ?RMA staff will administer and manage medications as prescribed by the resident?s physicians for the maintenance of their health and wellbeing as is possible.? 2. Regarding the duties of registered medication aides (RMAs) when providing assistance with oral medication administration, section 4.2 of the Commonwealth of Virginia Board of Nursing Medication Aide Curriculum for Registered Medication Aides, revised 05/21/2013, pages 122-123 state the following: ?11. Stay with the client until he/she has swallowed the medications (check mouth PRN).? 3. During on-site inspection on 05/06/2022, collateral 1 observed a small, white cup with four pills sitting on the table beside the bed in resident 2 room. 4. Staff 1 revealed to collateral 1 that he was the staff person administering medications the night before the on-site inspection, and at the time that staff 1 went to administer resident 2 his scheduled night time medications, the resident was eating and staff 1 left the pills with the resident and did not go back to make sure that the resident had taken the pills.
Plan of Correction:	Administrator to review Standard Medication Administration as stated by The Virginia Board of Nursing Medication Aide for Registered Medication Aides with all facility Medication Aides.
Standard #:	22VAC40-73-870-E
Complaint related:	Yes
Description:	Based on observation during a tour of the physical plant, the facility failed to ensure that all fixtures, including window coverings, toilets, and bathtubs, were kept clean and in good repair and condition. EVIDENCE: 1. The bathtubs were noted to have areas of a paint-like substance that was chipping/peeling off in the following rooms: 2, 4, 8, 9, 10, and 11. 2. Interview with staff 1 indicated that the facility uses a substance that is applied on the bathtubs of those rooms. 3. The toilet seat in room 8 was observed to have discoloration and was peeling. 4. The window in the shower of room 9 lacked a window covering. 5. The linoleum in the bathroom of room 2 was noted as peeling away from the base of the tub, and there was a piece of linoleum missing beside the threshold into the bathroom of room 4.
Plan of Correction:	1.Facility to ensure all fixtures, including window coverings, toilets, and bathtubs remain in good repair and condition. 2. Facility maintenance will conduct monthly inspections of all rooms and conduct repairs as needed within a timely manner 3. Facility to maintain monthly inspection logs and document findings accordingly.