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: Aug. 1, 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 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-80 COMPLAINT INVESTIGATION

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: 08/01/2022 08:30 AM ? 12:00 PM; 08/03/2022 01:40 PM ? 02:10 PM 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 07/28/2022 regarding allegations in the area(s) of: Building and grounds, food and nutrition and special diets, administrator responsibilities and supervision, safeguarding resident?s funds, staff criminal record checks, and qualifications of staff administering medications. 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: 4 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s), area(s) of non-compliance with standard(s) or law were valid. A violation notice was issued; any violation(s) not related to the complaint(s) 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 #:	22VAC40-73-190-A
Complaint related:	No
Description:	Based on observation, when the administrator, the designated assistant, or the manager is not awake and on duty on the premises, there shall be a direct care staff member in charge on the premises. EVIDENCE: 1. On 08/03/2022 at approximately 01:40 PM, LI and collateral 1 arrived at the facility to interview staff 3 as part of the complaint investigation. This LI and collateral 1 were met by staff 4 who advised that staff 3 was not working that day, staff 2 had left the facility to run an errand, and staff 5 was on her lunch break. Staff 4 revealed that she is only a dietary staff member and that there were no direct care staff members on the premises at that time. Approximately ten minutes later, staff 2 entered the facility and stated that he had been up the street to get a smoothie and confirmed that the person in charge while he and staff 5 were out of the building was staff 4.
Plan of Correction:	Facility to ensure all staff are crossed trained in Direct Care to ensure a direct care staff member is in the facility at all times.
Standard #:	22VAC40-73-250-B
Complaint related:	No
Description:	Based on observation and staff interview, the facility failed to ensure that all staff records shall be retained at the facility, treated confidentially, and kept in a locked area. EVIDENCE: While performing the on-site complaint investigation, LI requested to review a staff record to verify credentials; however, staff 1 and staff 2 stated that the staff records are not in the facility.
Plan of Correction:	Administrator to ensure staff files are on premises at all times.
Standard #:	22VAC40-73-680-A
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that staff who are licensed, registered, or acting as medication aides on a provisional basis shall administer drugs to those residents who are dependent on medication administration as documented on the UAI. EVIDENCE: 1. At the renewal inspection on 07/27/2022, the record for staff 3 contained a certification letter, dated 05/25/2022, that staff 3 had completed the 68-hour medication administration program through WellnessConcepts. The letter also indicated that she was not authorized to pass medications in a facility until she has passed her Registered Medication Aide exam or until she receives her letter to act as a Provisional Medication Aide for 120 days while waiting to take her Registered Medication Aide exam. 2. While investigating a complaint at the facility on 08/01/2022, LI and collateral 1 reviewed a sample of resident medication administration records (MARs) for May, June, and July 2022. 3. This LI and collateral 1 observed that staff 3 had initialed resident 1 MARs as being given on 05/28/2022 at 07:30 AM and 08:00 AM; on 06/06/2022 at 07:30 AM, 08:00 AM, 09:00 AM, 11:00 AM, and 11:30 AM; on 06/08/2022 at 07:00 AM, 07:30 AM, and 08:00 AM; 06/21/2022 at 07:00 AM, 07:30 AM, 08:00 AM, and 09:00 AM; on 06/22/2022 at 07:00 AM, 07:30 AM, 08:00 AM, 09:00 AM, 11:00 AM, and 02:00 PM; on 06/23/2022 at 07:00 AM, 07:30 AM, 08:00 AM, 11:00 AM, and 11:30 AM; on 06/24/2022 at 07:00 AM, 07:30 AM, and 08:00 AM; on 06/26/2022 at 11:00 AM, 11:30 AM, and 02:00 PM; on 07/01/2022 at 07:00 AM, 07:30 AM, 08:00 AM, and 09:00 AM; on 07/04/2022 at 07:00 AM, 07:30 AM, 08:00 AM, 11:00 AM, and 11:30 AM; on 07/05/2022 at 07:00 AM, 07:30 AM, 08:00 AM, 11:00 AM, and 11:30 AM; on 07/07/2022 at 11:00 AM and 11:30 AM; on 07/08/2022 at 07:00 AM, 07:30 AM, 08:00 AM, 11:00 AM, and 11:30 AM. 4. When LI asked for verification that staff 3 had received her provisional RMA letter which allowed her to pass medications, staff 1 and staff 2 were unable to provide verification that the provisional letter had been received.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-750-B
Complaint related:	No
Description:	Based on observation, the facility failed to ensure that resident bedrooms shall contain an operable bed lamp or bedside light accessible to each resident. EVIDENCE: While visually inspecting room 3 at approximately 08:47 AM, LI and collateral 1 observed that neither bed had a bedside lamp or bedside light.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-860-G
Complaint related:	No
Description:	Based on observation, the facility failed to ensure that hot water at taps shall be maintained within a range of 105 degrees Fahrenheit and 120 degrees Fahrenheit. EVIDENCE: 1. While performing the on-site complaint investigation at approximately 09:17 AM on 08/01/2022, collateral 1 observed that the water temperature for the bathtub in room 14 did not exceed 89 degrees Fahrenheit despite allowing it to run for around five minutes. A follow up temperature check for the bathtub in room 14 at approximately 10:45 AM indicated approximately 91 degrees Fahrenheit. 2. In room 13, this LI observed that the water temperature for the sink was approximately 69.3 degrees Fahrenheit, and the shower temperature reading was approximately 89 degrees Fahrenheit despite allowing it to run for five minutes.
Plan of Correction:	Facility is actively working with local plumbing company to assess why water temperatures are not reaching optimal temperatures throughout all rooms in facility.
Standard #:	22VAC40-73-925-A
Complaint related:	No
Description:	Based on observation, the facility failed to have an adequate supply of toilet tissue and soap. Toilet tissue shall be accessible to each commode and soap shall be accessible to each face/hand washing sink and each bathtub or shower. EVIDENCE: While performing the on-site complaint investigation at approximately 08:45 AM, LI observed that the bathrooms inside of rooms 5, 13, and 14 did not have toilet paper or soap for resident use.
Plan of Correction:	Not available online. Contact Inspector for more information.