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: March 23, 2021

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 3/23/2021 and concluded on 3/25/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 79. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, health care oversight, staff schedules, fire and health department inspections, fire drill logs, dietician oversight and new employee sworn disclosure and criminal records submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1110-A
Description:	Based on a review of resident records, the facility failed to ensure that written determination and justification was provided by the licensee, administrator or designee prior to place to a special care unit. EVIDENCE: 1. The record for resident 2, admitted to the facility special care unit on 1/29/21, did not contain written determination and justification prior to the residents placement in a special care unit.
Plan of Correction:	Required form for SCU placement in use form for all admissions to SCU. ED and/or designee to ensure appropriate placement form used for each new admission.
Standard #:	22VAC40-73-1140-B
Description:	Based on a review of staff records, the facility failed to ensure that direct care staff attended at least 10 hours of training in cognitive impairments within four months of thier start date of employment. EVIDENCE: 1. The record for staff person 2, hired on 10/16/20, did not contain any documentation of training for residents with cognitive impairments. In an interview with staff person 6 it was expressed that this employee does work at times on the facility safe secure unit with residents who has cognitive impairments.
Plan of Correction:	BOM or ED to schedule cognitive training for staff person 2 to begin immediately upon return from leave. At orientation, BOM or designee to assign/schedule cognitive training to be completed over following 4 months for each new direct care staff.
Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records, the facility failed to ensure that all direct care staff maintained certification in first aid. EVIDENCE: 1. The record for staff person 4, hired on 10/17/19, did not contain a current first aid certification card from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. A notation was made on staff person 4's relias training record for first aid on 10/21/19 but the notation did not include the entity that provided the training or the time frame that the certification was valid for.
Plan of Correction:	BOM and/or designee to audit certifications monthly for expiring certifications. Schedule classes as needed to provide appropriate training .
Standard #:	22VAC40-73-270-1
Description:	Based on a review of staff records, the facility failed to ensure that direct care staff received training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. This training shall include, at a minimum, information, demonstration, and practical experience in self-protection and in the prevention and de-escalation of aggressive behavior. EVIDENCE: 1. The record for staff person 2, hired on 10/16/20, did not contain documentation that this employee has received training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. In an interview with staff person 6 it was expressed that this employee works at times on the facility safe secure unit where resident 2, whos record has documentation of aggressive behavior on at least one occasion, resides. 2. The record for staff person 3 has documentation on their relias training record of receiving aggressive behavior training on 10/15/19 and 4/17/20. The training record does not include a written description of the content of this training to also include any demonstration and practical experience provided or a notation of the qualified health professional who provided the training. 3. The record for staff person 4 has documentation on their relias training record of receiving aggressive behavior training on 10/10/19 and 4/17/20. The training record does not include a written description of the content of this training to also include any demonstration and practical experience provided or a notation of the qualified health professional who provided the training.
Plan of Correction:	WD to conduct Behavior Training with all direct care staff. Training will be conducted as part of orientation for all new direct care staff.
Standard #:	22VAC40-73-280-A
Description:	Based on a review of resident records and staffing daily assignment sheets, the facility failed to ensure that staffing was sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident. EVIDENCE: 1. The record for resident 2, who resides in the facility safe secure unit, has documentation on his individualized service plan ( ISP) of the resident requiring assistance of 2 staff for transfers and toileting assistance every 2 to 3 hours for bladder incontinence. Progress notes in resident 2's record has documentation on 2/1/21 of the resident requiring assistance of 4 staff for transferring and on 2/6/21 requiring assistance of 3 staff for transferring. The progress notes also has documentation during the 11 to 7 shift on 2/6/21, 3/1/21, 3/17/21 and 3/18/21 of the resident falling and EMS being called for assistance to get the resident up from the floor and assist in putting him back to bed. Daily staffing assignment sheets has documentation that only 2 direct care staff were present on the safe secure unit for 14 shifts between 3/2/21 and 3/21/21. During these shifts that only 2 direct care staff were present and were providing care for resident 2's transfer needs, no other direct care staff were scheduled to be on the unit to assist in the care needs of other residents.
Plan of Correction:	Continue to schedule daily number of staff to meet DSS requirements. WD, AWD or designee BOM to continue recruitment efforts to ensure ample staff available.
Standard #:	22VAC40-73-325-B
Description:	Based on a review of resident records, the facility failed to ensure that fall risk ratings were completed annually. EVIDENCE: 1. The record for resident 3, who was assessed as assisted living level of care on their most recent uniform assessment instrument (UAI) dated 2/17/21, has documentation that the last fall risk rating completed for this resident was dated 1/28/20.
Plan of Correction:	Resident 3 Fall risk rating updated at time of inspection. WD, AWD, and/or designee to complete full audit of fall risk ratings. WD to create system to track Fall Risk rating needs.
Standard #:	22VAC40-73-440-D
Description:	Based on a review of resident records, the facility failed to ensure that private pay uniform assessment instruments (UAIs) were competed as required. EVIDENCE: 1. The UAI dated 1/29/21 in the record for resident 2 has documentation that the residents medications are administered/monitored by professional nursing staff. It was noted that the UAI should indicate that medications are administered/monitored by lay persons as registered medication aides administer medications to this resident. 2. The UAI dated 9/16/20 in the record for resident 4 has documentation that the residents medications are administered/monitored by professional nursing staff. It was noted that the UAI should indicate that medications are administered/monitored by lay persons as registered medication aides administer medications to this resident.
Plan of Correction:	UAI for residents 2 & 4 updated at time of inspection. Full audit on all UAIs. WD, AWD, and/or designee
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility to ensure that all identified needs were addressed on residents individualized service plans (ISPs). EVIDENCE: 1. The record for resident 1 has documentation that the resident has a Do Not Resuscitate (DNR) order. The comprehensive ISP dated 11/6/20 does not address this identified need. 2. The comprehensive ISP dated 1/29/21 in the record for resident 2 has documentation of the resident being a fall risk. The residents record has documentation of the resident falling 7 times since 1/29/21 but the ISP does not reflect any additional measures put in place to prevent/reduce further falls, including the identified need for a bed alarm ordered on 1/30/31 and the identified need for a bed side commode ordered on 1/29/21. The record for resident 2 also has a physician order for physical and occupational therapy services dated 2/2/21 but this identified need is not addressed on the ISP. 3. The fall risk rating completed on 1/28/20 in the record for resident 3 has indicates that the resident is a high risk for falls. The comprehensive ISP dated 2/17/21 does not address this identified need. 4. The fall risk rating completed on 2/2/21 in the record for resident 4 has indicates that the resident is a high risk for falls. The comprehensive ISP dated 9/16/20 does not address this identified need. Also the progress notes for resident 4 has documentation that the resident has been receiving Home Health Therapy services and will be transitioning to facility in house therapy. The ISP does not address the identified need for this residents therapy services.
Plan of Correction:	ISP for resident 1 updated at time of inspection to reflect all identified needs are addressed. WD, AWD, ED to complete full audit on all current ISPs. Begin weekly audit on 5 resident ISPs completed by WD, AWD and/or designee.
Standard #:	22VAC40-73-450-D
Description:	Based on review of resident record, the facility failed to ensure that the services provided by both, the assisted living facility and the licensed hospice organization, were included on the individualized service plan (ISP). EVIDENCE: 1. The record for resident 1 shows the resident is receiving hospice services. The comprehensive ISP for resident 1, dated 11/6/20, indicates the resident is receiving hospice services, but does not include the services provided by the hospice organization. 2. The record for resident has documentation that the resident is receiving Hospices services since 9/17/20. The comprehensive ISP dated 9/16/20 doe not address any Hospice services being provided to the resident.
Plan of Correction:	ISP for resident 1 updated at time of inspection to include hospice services. WD, AWD, ED to complete full audit on resident's ISPs currently receiving hospice services. Begin weekly audit on 5 resident ISPs completed by WD, AWD and/or designee.
Standard #:	22VAC40-73-640-A
Description:	Based on a review of resident records and the facility medication management plan, the facility failed to follow their medication management plan in regards to methods for verifying that orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order. EVIDENCE: 1. The facility medication management plan has documentation that the wellness director of community designee will review new orders transcribed into PCC within 24 hours of a new or change in order. If any order was noted to be transcribed inaccurately, verify order and correct documentation. The record for resident 3 has a physician order dated 2/16/21 to encourage the resident to take PO fluids. This physician order was not transcribed on the Residents March 2021 medication administration record.
Plan of Correction:	Order for resident 3 transcribed to the residents MAR on date of inspection. WD, AWD, and/or designee to complete ongoing audit for orders to be transcribed to the MAR. WD to provide Medication management plan in-service for LPNs and RMAs.
Standard #:	22VAC40-73-650-A
Description:	Based on a review of resident records, the facility failed to ensure that no medication was changed without a valid order from a physician. EVIDENCE: 1. The record for resident 1 has documentation of a physician order dated 11/3/2020 for the resident to be NPO for diet, texture and consistency, no food or fluids by mouth. The record also has physician orders dated 11/7/2020 for Ativan 0.5 mg 1 tablet by mouth every 6 hours as needed and Oxycodone 5mg, 1 tablet by mouth every 4 hours as needed. No clarification was received to change the original order dated 11/3/20 that the resident is to be NPO and take nothing by mouth.
Plan of Correction:	Order for resident 1 clarified with physician and record updated. WD to provide education to Charge Nurses regarding order clarification. WD, AWD, and/or designee to begin weekly chart audits to ensure orders are correct.
Standard #:	22VAC40-73-680-I
Description:	Based on a review or resident medication administration records (MARs), the facility failed to ensure that all required documentation was present on resident MARs. EVIDENCE: 1. The March 2021 MAR for resident 1 does not have staff initials for the administration of the medication Carbidopa/Levodopa 25/100mg at 1pm on 3/7/2, Jevity tube feedings at 1pm on 3/7/21 and 5am on 3/14/21 and tube flushes at 1pm on 3/7/21 and 5am on 3/14/21. 2. The March 2021 MAR for resident 2 does not have staff initials for the administration of Buspirone 10mg at 2pm on 3/1/21or Voltaran Gel at 9pm on 3/6/21 and 3/11/21. 3. The March 2021 MAR for resident 3 does not have staff initials for the administration of Fosamax 70mg at 630am on 3/17/21.
Plan of Correction:	WD to provide Medication management plan in-service for LPNs and RMAs. WD and AWD to check dashboard daily for alerts.