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. 17, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint # 57679 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/18/2023 from 09:00 AM until 02:30 PM; 07/30/2023 from 10:30 AM until 12:00 PM; 08/17/2023 from 11:00 AM until 12:00 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 07/17/2023 regarding allegations in the area(s) of: Administration and administrative services; Admission, retention, and discharge of residents. Number of residents present at the facility at the beginning of the inspection: 17 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: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 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 the allegation(s) of non-compliance with standard(s) or law, and violation(s) were 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 #:	22VAC40-73-80
Complaint related:	No
Description:	Based on record review and staff interview, for a facility that assists with the management of resident personal funds, the facility failed to maintain in a resident?s record a copy of a written accounting of money received and disbursed by the facility that shows a current balance. EVIDENCE: 1. During the 07/18/2023 complaint investigation, the record for resident 2 did not contain at least quarterly documentation of written accounting of money received and disbursed by the facility that shows a current balance. 2. During the 08/17/2023 complaint investigation follow-up, LI requested to review the quarterly documentation of written accounting for resident 2; however, staff 2 revealed that it was not in the resident?s record to review at that time.
Plan of Correction:	The facility will provide each resident or the resident?s legal representative a monthly statement that itemizes any charges made by the facility and any payments received from the resident or on behalf of the resident during the previous calendar month and shall show the balance or any credits for overpayment. The facility shall also place a copy of the monthly statement in the resident?s record as well as a copy signed by the resident in the facility computer database available for review and/or print upon request.
Standard #:	22VAC40-73-90
Complaint related:	No
Description:	Based on record review and staff interview, for a licensee or facility administrator that acts as the trustee of a resident?s funds, the facility failed to maintain in a resident?s record a copy of a written accounting of money received and disbursed by the licensee, facility administrator, or staff person that shows a current balance. EVIDENCE: 1. During the 07/18/2023 complaint investigation, the record for resident 2 did not contain at least quarterly documentation of written accounting of money received and disbursed by the facility that shows a current balance. 2. During the 08/17/2023 complaint investigation follow-up, LI requested to review the quarterly documentation of written accounting for resident 2; however, staff 2 revealed that it was not in the resident?s record to review at that time.
Plan of Correction:	The facility will provide each resident or the resident?s legal representative a monthly statement that itemizes any charges made by the facility and any payments received from the resident or on behalf of the resident during the previous calendar month and shall show the balance or any credits for overpayment. The facility shall also place a copy of the monthly statement in the resident?s record as well as a copy signed by the resident in the facility computer database available for review and/or print upon request.
Standard #:	22VAC40-73-400
Complaint related:	No
Description:	Based on record review and interviews, the facility failed to provide to each resident or the resident?s legal representative a monthly statement that itemizes any charges made by the facility and any payments received from the resident or on behalf of the resident during the previous calendar month and shall show the balance or any credits for overpayment. The facility shall also place a copy of the monthly statement in the resident?s record. EVIDENCE: 1. During the 07/18/2023 complaint investigation, the records for residents 1, 2, 3, and 4 did not contain documentation of monthly statements. On the same date, LIs requested to see copies of the monthly statements for residents; however, staff 1 advised that that documentation is only accessible by staff 2, who is not coming to the facility that day. 2. During the 07/31/2023 complaint investigation follow-up, staff 2 was unable to provide verification of monthly statements for residents 1, 2, 3, and 4 from the month of January 2023 to July 2023 when requested.
Plan of Correction:	The facility will provide each resident or the resident?s legal representative a monthly statement that itemizes any charges made by the facility and any payments received from the resident or on behalf of the resident during the previous calendar month and shall show the balance or any credits for overpayment. The facility shall also place a copy of the monthly statement in the resident?s record as well as a copy signed by the resident in the facility computer database available for review and/or print upon request.