VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Woodland Hills Independent Living, Assisted Living & Memory Care
3365 Ogden Road
Roanoke, VA 24018
(540) 682-7500

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: April 23, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 4/23/2020 and concluded on 4/23/2020. The facility administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 53. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, facility health care oversight, fire drills, health department inspection, dietitian oversight, activity calendar and staff schedules submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on a review of resident records, the facility failed to ensure that an assessment of serious cognitive impairment was completed by a physician prior to placing a resident in a safe, secure unit. EVIDENCE: 1. The record for resident 4 has documentation that the resident was moved from the facility AL side to the safe, secure unit on 3/28/2020. A physician order dated 3/27/2020 to move the resident to a safe secure unit due to the residents inability to recognize danger and serious cognitive issues was noted in the record. The order did not contain documentation of resident 1's Cognitive functions (e.g., orientation, comprehension, problem-solving, attention and concentration, memory, intelligence, abstract reasoning, judgment, and insight); Thought and perception (e.g., process and content); Mood/affect; Behavior/psycho-motor; Speech/language; and Appearance.
Plan of Correction:	1. WD or designee will work with Medical Director to generate an assessment of serious cognitive impairment for resident 4 by 5/10/20. 2.WD or designee will audit active resident files and obtain assessment of serious cognitive impairment by 5/31/2020. 3. Moving forward, the WD or designee will keep services available for residents as identified.
Standard #:	22VAC40-73-1110-A
Description:	Based on a review of resident records, the facility failed to ensure that written justification from the administrator or designee for appropriate placement to a safe, secure unit was maintained in the residents records. EVIDENCE: 1. The record for resident 4, admitted to the facility safe, secure unit on 3/28/2020 did not contain written justification for the appropriate placement to the safe, secure unit from the facility administrator or designee.
Plan of Correction:	1. ED or designee will work to generate written justification for appropriate placement to a safe, secure unit for resident 4 by 5/10/20. 2. ED or designee will audit active resident files and obtain written justification for appropriate placement to a safe, secure unit for resident 4 by 5/31/20. 3. Moving forward, the ED or designee will keep services available for residents as identified.
Standard #:	22VAC40-73-325-A
Description:	Based on a review of resident records, the facility failed to ensure that a fall risk rating was completed after a resident has fallen. EVIDENCE: 1. The record for resident 2, assessed as assisted living level of care, has documentation of the resident falling on 3/27/2020. The record did not contain documentation of a fall risk rating being completed after this fall.
Plan of Correction:	1. WD discovered documentation errors earlier in the month for resident 2 and addressed it with Wellness team. Training issued to team in the month of April 2020. 2. Resident 2 file will be audited by WD or designee to ensure compliance with fall risk ratings by 5/10/2020.3. Active Resident files will be corrected by WD or designee to ensure compliance with fall risk rating is received by 5/31/2020.4. Moving forward, the WD or designee will conduct monthly audits on fall risk ratings as falls happen in the community until 7/31/2020.
Standard #:	22VAC40-73-440-D
Description:	Based on a review of resident records, the facility failed to ensure that uniform assessment instruments (UAI's) were completed as required. EVIDENCE: 1. The UAI's for residents 1, 2, 3 and 4 has documentation that the resident?s medication is administered/monitored by professional nursing staff. The facility employees registered medication aides (RMA's) who administer medications. RMA's are under laypersons on the UAI form.
Plan of Correction:	1. The WD or designee will correct the UAI for resident 1, 2, 3, 4 by 5/10/20. 2. The WD or designee will work with the RUI Home Office and State Inspector to determine the best way to move forward between 22VAC40-73-680 and this regulation. 3. The Wellness Director or designee will audit active resident records to ensure that the UAI displays the appropriate documentation by 7/31/20.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that identified needs were addressed on individualized service plans (ISP's). EVIDENCE: 1. The history and physical dated 2/17/2020 in the record for resident 1 has documentation that the resident requires mental health services for psychiatric follow-up. The ISP dated 4/17/2020 for resident 1 does not address this identified need.
Plan of Correction:	1. The WD or designee will get psychiatric services for resident 1 by 7/31/2020. 2. The WD or designee will audit active resident files and fulfill needs of psychiatric services by 7/31/2020. 3. Moving forward, the WD or designee will keep psychiatric services available for residents as identified.
Standard #:	22VAC40-90-40-B
Description:	Based on review of staff records, the facility failed to ensure that a criminal record check was obtained on five employees within 30 days of employment. EVIDENCE: 1. The criminal record check for staff 1, hired on 3/3/2020, was not obtained until 4/7/2020. 2. The criminal record check for staff 2, hired on 2/5/2020, was not obtained until 4/23/2020. 3. The criminal record check for staff 5, hired on 3/10/2020, was not obtained until 4/23/2020. 4. The criminal record check for staff 6, hired on 2/18/2020, was not obtained until 4/23/2020.
Plan of Correction:	1. VSP Background Check login received on 4/23/20. This will be used to check backgrounds moving forward. 2. Active Staff files will be audited by ED, HRM, or designee to ensure compliance with VSP background checks by 5/10/2020. 3. Active staff files will be corrected by ED, HRM, or designee to ensure VSP is received by 5/10/2020. 4. Moving forward, the ED, HRM, or designee will conduct VSP background checks during the hiring/orientation process. 5. New staff background checks will be audited by the ED or designee to ensure compliance through 7/31/2020.