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: Dec. 20, 2021

Complaint Related: Yes

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 BUILDING AND GROUNDS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

The LI for Woodland Hills conducted an on-site complaint investigation on 12/20/2021 in conjunction with another LI. A tour of the facility special care unit was conducted and interviews were held with staff. Resident records as well as other forms of facility documentation were reviewed. An exit interview was conducted with the facility Administrator and the opportunity was given for additional documentation to be provided. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-1130-C
Complaint related:	Yes
Description:	Based on a review of facility staffing sheets and employee schedule, the facility failed to ensure that at least 3 direct care staff members were awake and on duty in the special care unit when 23 to 32 residents were present. EVIDENCE: 1. The facility special care unit was noted to have a census of 25 on the day of inspection. The facility daily staff staffing sheets has documentation of only 2 direct care staff members working on the special care unit on the 11pm to 7am shift on 10/06/2021, 10/07/2021, 10/09/2021, 12/03/2021, 12/07/2021, and 12/18/2021. Interviews with staff person 1 expressed that the special care unit census was been between 23 and 32 residents during these shifts, which would require a minimum of 3 direct care staff on duty on the special care unit..
Plan of Correction:	Executive Director to review schedule daily to ensure appropriate number of staff are on schedule to meet DSS requirements. DCS, DICSE, or designee BOM to ensure staff are available based on secure unit staffing regulation and acuity of residents. ? 3/18/22 ? To be monitored by ED, DCS, DICSE, BOM
Standard #:	22VAC40-73-280-A
Complaint related:	Yes
Description:	Based on resident record review, the assisted living facility failed to ensure staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans (ISPs). EVIDENCE: 1. The facility had an incident report for resident 2, dated 10/23/2021 at 10:00PM, which showed ?CNA observed resident on floor during rounds. Resident assessed, 911 called for assistance in lifting resident safely back to bed.? The facility daily staffing sheet has documentation of 3 direct care staff members schedule for the facility memory care unit, where resident 2 resides.
Plan of Correction:	Executive Director to review schedule daily to ensure appropriate number of staff are on schedule to meet DSS requirements. DCS, DICSE, or designee BOM to ensure staff are available based on secure unit staffing regulation and acuity of residents. ? 3/18/22 ? To be monitored by ED, DCS, DICSE, BOM
Standard #:	22VAC40-73-325-B
Complaint related:	Yes
Description:	Based on resident record review, the facility failed to ensure that the fall risk rating was reviewed and updated after a fall for residents who meet the criteria for assisted living care. EVIDENCE: 1. The uniform assessment instrument (UAI), dated 06/04/2021 for resident 2 has them assessed as assisted living level of care. The record for resident 2 contained an incident note from nursing, dated 10/11/2021, that stated ?Note Text: Resident found sitting in bathroom floor. Alert with no complaints of pain, dizziness, or LOC. Skin tear noted on LFA. Cleansed with NS, steri-strips applied and covered with Kling. Resident cleansed, brief changed, dressed and shaved. Sitting in recliner with no complaints. DON spoke with spouse.? The record for resident 2 did not contain a fall risk rating for this fall.
Plan of Correction:	Resident 2 file will be audited by DCS or designee to ensure compliance with fall risk ratings by 3/11/22. The DCS or designee will conduct weekly audits on fall risk ratings. ? 3/31/22 ? To be monitored by DCS
Standard #:	22VAC40-73-440-D
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure for private pay individuals the uniform assessment instrument (UAI) was completed as required by 22VAC30-110. EVIDENCE: 1. The UAI dated 01/29/2021 in the record for resident 1 does not contain the signature of the person who completed the assessment or the Administrator or designee. 2. The UAI dated 06/04/2021 in the record for resident 2 does not contain the signature of the administrator or designee.
Plan of Correction:	The DCS or designee will correct the UAI for Resident 1 and 2 by 3/11/22. The DCS or designee will audit active resident records to ensure that the UAI displays the appropriate documentation by 4/30/22. ? 4/30/22 ? To be monitored by DCS
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the by the licensee, administrator, or his designee, (i.e., the person who has developed the plan) or the resident or his legal representative. EVIDENCE: 1. The ISP in the record for resident 1 does not have a signature of the person who completed the plan, the date the plan was completed or signature of the resident or their legal representative. 2. The ISP dated 06/10/2021 in the record for resident 2 does not contain the signature of the resident or his legal representative.
Plan of Correction:	The DCS or designee will contact the resident and/or POA and the comprehensive ISP for Resident 1 and 2 will be reviewed with the resident and family and a signature obtained by 3/11/22. The DCS or designee will audit weekly resident ISPs to ensure that the ISP displays a resident or family signature until 3/31/22. ? 3/31/22 ? To be monitored by DCS
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on resident record review and staff interview, the facility failed to review and update the individualized service plan (ISP) as the condition of a resident changes. EVIDENCE: 1. The record for resident 1 has documentation of the resident falling/found on the floor on 09/25/2021, 10/20/2021, 10/26/2021, 11/30/2021 and 12/09/2021. The ISP in the record for resident 1 does not have documentation of any additional needs for monitoring or fall prevention since 01/29/2021. 2. The facility had documentation, fall risk ratings and incident reports, that showed resident 2 had nine falls between 09/16/2021 through 12/12/2021. The fall risk ratings for resident 2 during this time period also indicate that the resident is a high fall risk. The ISP for the resident, dated 06/10/2021, does not indicate that the resident is a high fall risk.
Plan of Correction:	? ISPs for Residents 1 and 2 will be updated to address fall prevention. This will be completed by 3/11/22. DCS and ED will monitor ISPs for accuracy during weekly meetings. ISP will be updated with significant change on resident by DCS/DICSE/designee. ? 2/11/22 ? To be monitored by DCS and ED
Standard #:	22VAC40-73-680-B
Complaint related:	No
Description:	Based on observation, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. EVIDENCE: 1. At approximately 10:21AM during on-site complaint inspection, the door to room 215, which is located in the facility?s safe, secure unit, was found to be unlocked by one licensing inspector (LI). The LI observed a small clear, plastic medication cup on the floor of the room that contained a pink paste that was labeled with resident 3?s name.
Plan of Correction:	? Appeal - Director of Clinical Services will review medication administration passes to ensure that all medications remain in pharmacy dispensed containers. A training of all LPNs and RMAs will be conducted using our medication management plan. ? 3/18/22 ? To be monitored by DCS, DICSE
Standard #:	22VAC40-73-700-2
Complaint related:	No
Description:	Based on observation, the facility failed to post ?No Smoking-Oxygen in Use? signs when oxygen therapy is provided. EVIDENCE: 1. Resident 4?s room contained an oxygen concentrator and one oxygen portable tank. The room did not contain a ?No Smoking-Oxygen in Use? sign.
Plan of Correction:	Oxygen signs were ordered and placed on Resident 4?s room door on 2/28/22. All rooms belonging to residents using oxygen have been checked to make sure proper signage is displayed. EVS will continue to monitor rooms for proper signage. ? 2/28/22 ? To be monitored by EVS and ED
Standard #:	22VAC40-73-860-I
Complaint related:	No
Description:	Based on observation, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: 1. At approximately 9:45AM during on-site complaint inspection, the door to the laundry room in the facility?s safe, secure unit was found by two licensing inspectors (LIs) to be propped open with a small towel. A container of sprayway glass cleaner, ecolab home-style laundry detergent packs and a plastic water bottle with a blue substance were noted to be located in the laundry room.
Plan of Correction:	Storage room door was adjusted to latch and lock. EVS to provide in-service with all housekeeping/maintenance staff of proper storage of cleaning supplies and hazardous materials. EVS or EVS assistant will monitor cleaning supplies and hazardous materials daily. ? 3/18/22 ? To be monitored by ED and EVS