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: Oct. 3, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/03/2022 09:30 AM ? 11:00 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 #:	22VAC40-73-270-4
Description:	Based on staff record review and staff interview, the facility failed to ensure that direct care staff shall be trained in methods of dealing with residents who have a history of aggressive behaviors or of dangerously agitated states prior to being involved in the care of such residents. This includes an annual refresher training for all direct care staff when aggressive residents are in care. EVIDENCE: 1. The record for staff 1, date of hire 05/02/2022, did not contain documentation of aggressive training prior to being involved in the care of such residents. 2. The record for staff 3, date of hire 09/10/2021, did not contain documentation of aggressive training prior to being involved in the care of such residents. 3. The record for staff 4 did not contain documentation of having aggressive behavior training since 2019. 4. Interview with staff 2 indicated that there are some residents of the facility with a history of aggressive behaviors; however, staff 1 and 3 haven?t yet received the initial aggressive behavior training, and staff 4 has not received annual training.
Plan of Correction:	Aggressive staff training has been scheduled for all staff attendance for 10/24/22.
Standard #:	22VAC40-73-680-I
Description:	Based on record review, the facility failed to ensure that the Medication Administration Record (MAR) shall include the date and time given and initials of direct care staff administering the medication. EVIDENCE: 1. The September 2022 MAR for resident 1 did not contain the medication administration staff initials on multiple dates and times for multiple medications. 2. The September 2022 MAR for resident 2 did not contain the medication administration staff initials for multiple medications and times on September 19, 2022. 3. The September 2022 MAR for resident 3 did not contain the medication administration staff initials on multiple dates and times for multiple medications.
Plan of Correction:	Administrator and/or designee are working with EMAR system developers to determine a route cause analysis for missing initials when staff are signing off on medication pass. Staff training to be conducted on developers recommendations once received.