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: Aug. 19, 2022

Complaint Related: No

Areas Reviewed:

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/19/2022 9:00am til 2:00pm Number of residents present at the facility at the beginning of the inspection: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of interviews conducted with staff: 6 An exit meeting will be conducted to review the inspection findings. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure all identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 03/10/2022, for ?fluid restriction 1500ml/day?. The ISP for resident 1, dated 11/18/2021, did not indicate this identified need.
Plan of Correction:	The Director of Clinical Services (DCS), Director of Clinical Inspiritas and Engagement (DCISE), or designee will audit active resident medical records to ensure that the comprehensive ISPs display the residents identified needs.
Standard #:	22VAC40-73-610-D
Description:	Based on a review of resident records, observations, and staff interview, the facility failed to ensure when a diet is prescribed for a resident by his physician or other prescriber, it is served according to the physician?s or other prescriber?s order. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 03/10/2022, for fluid restriction of 1500ML per day. During observations made of the facility?s kitchen, one licensing inspector observed that the kitchen?s special diet listing did not contain documentation of resident 1?s order for fluid restriction of 1500ML per day. Interview with staff person 6 revealed that he was not aware of the aforementioned fluid restriction physician?s order for resident 1. Interviews with staff persons 1 and 3 indicated that resident 1?s fluid intake was not being recorded to ensure that the facility was only offering 1500ml of fluids daily to the resident between medication passes, dietary and activities.
Plan of Correction:	Diets will be audited by the Director of Clinical Services (DCS), Director of Clinical Inspiritas and Engagement (DCISE), or designee and ensure all orders are being followed. Dietary team will be given updates with any order change.
Standard #:	22VAC40-73-640-A
Description:	Based on observations made during a medication cart audit, resident record reviews, document review and staff interviews, the facility failed to implement their medication management plan. EVIDENCE: 1. During a medication cart audit on 08/19/2022 and an interview with staff person 4, it was revealed that the facility did not have resident 1?s scheduled Ferrous Sulfate 325MG or resident 2?s scheduled Sertraline 25MG. The facility?s medication management plan states the following: ?The Community staff should review all on-demand medications daily and re-order when a 5-day supply of the medication is remaining.? 2. The Controlled Narcotic Count Sheets on the memory care unit and the wellness first floor medication carts were noted to be missing staff signatures for the coming on and going off narcotic counts. The facility?s medication management plan states the following ? The community should ensure that the incoming and outgoing nurse or designee count all controlled medications at least once per shift and document the results on the controlled drug count verification/shift count sheet?.
Plan of Correction:	The Director of Clinical Services (DCS), Director of Clinical Inspiritas and Engagement (DCISE), or designee to complete daily audit of medication administration compliance. DCS to provide medication management plan in-service for LPNs and RMAs. - To be monitored by DCS and Executive Director (ED)
Standard #:	22VAC40-73-660-A-6
Description:	Based on observations made of the facility medication carts, the facility failed to ensure that medications requiring refrigeration were refrigerated. EVIDENCE: 1. The wellness cart on the first floor contained a bottle of Lorazepam liquid in the dart for resident 2. Manufacturer instructions on the box indicate to store at cold temperature, refrigerate at 36? to 46? F.
Plan of Correction:	All medication carts will be audited by designee to ensure medications are stored properly. Training will be completed to RMA and LPNs on proper storage.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and staff interview, the facility failed to ensure medications were administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 03/15/2022, for Ricola cough drops as needed every six hours for cough and congestion. Interview with staff persons 1 and 3 revealed that the resident has the aforementioned cough drops in her room; however, the physician?s order does not indicate that resident 1 can self-administer the cough drops. 2. The record for resident 1 contained a physician?s order, dated 08/09/2022, for Ibuprofen 600mg every 8 hours for gout for five days. The August 2022 medication administration record (MAR) for resident 1 contained documentation that the resident was not administered the aforementioned medication on 08/10/2022 through 08/14/2022 at ?0000? hours because the resident was asleep. The physician?s order does not indicate that the medication may be held due to the resident sleeping. Also, during on-site inspection on 08/19/2022, it was observed by two licensing inspectors and staff person 4 that the blister card for the Ibuprofen 600mg still contained four Ibuprofen 600mg tablets even though the medication had ended.
Plan of Correction:	The Director of Clinical Services (DCS), Director of Clinical Inspiritas and Engagement (DCISE), or designee will provide education to the RMA(s) on administering medications in accordance with physician or other prescriber?s instructions. DCS or designee to provide in-service to all RMAs and LPNs regarding administering medications in accordance with physician instructions. ? To be monitored by DCS or designee.
Standard #:	22VAC40-73-680-E
Description:	Based on a review of resident records and staff interview, the facility failed to ensure medical treatments ordered by a physician or other prescriber were provided according to his instructions and documented. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 03/20/2022, for Oxygen at 2L/min via nasal cannula. The record for the resident did not contain documentation that staff monitor resident 1?s Oxygen usage. Interviews with staff persons 1 and 3 revealed that the resident self-administers her Oxygen; however, the physician?s order does not indicate that resident 1 can self-administer Oxygen. 2. The record for resident 2 contained a physician?s order, dated 12/31/2021, for Calmoseptine Ointment apply every shift. The August 2022 treatment administration record (TAR) for resident 2 contained documentation of multiple shifts that did not include documentation that Calmoseptine Ointment had been applied to the resident. 3. The record for resident 3 contained physician?s orders, dated 07/20/2021, 02/24/2022, and 03/20/2022, for staff to continue to monitor area on left face for changes (increased size, scaly, bleeding or complaints). The record for resident 3 did not contain documentation that staff have been monitoring the aforementioned physician?s order. Interviews with staff person 1 and 3 indicated this is accurate and that there was no order to discontinue the monitoring of the area on the left side of resident 3?s face.
Plan of Correction:	The Director of Clinical Services (DCS), Director of Clinical Inspiritas and Engagement (DCISE), or designee will provide medication management plan in-service for all RMAs and LPNs. DCS, DCISE, or designee to complete daily audit of medication administration or treatment administration compliance. ? To be monitored by DCS, DCISE, or designee
Standard #:	22VAC40-73-680-M
Description:	Based on observations made during a medication cart audit and staff interview, the facility failed to ensure medication ordered for PRN (as needed) use were available at the facility. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 08/09/2022, for Tylenol 650mg every 8 hours as needed for pain. Interview with staff person 4 revealed the medication was not available at the facility during on-site inspection. 2. The record for resident 1 contained a physician?s order, dated 12/31/2021, for Hydromorphone give 0.5ml every four hours as needed for pain or shortness of breath and Calcium Carbonate give 1000ML every six hours as needed for heartburn. Interview with staff person 4 revealed the medication was not available at the facility during on-site inspection. 3. The record for resident 3 contained a physician?s order, dated 03/20/2022, for Bio freeze apply to chest topically as needed for chest swelling with pain. Interview with staff person 4 revealed the medication was not available at the facility during on-site inspection.
Plan of Correction:	The Director of Clinical Services (DCS), Director of Clinical Inspiritas and Engagement (DCISE), or designee will provide medication management plan in-service for all RMAs and LPNs. DCS and DCISE to complete daily audit of medication administration compliance.
Standard #:	22VAC40-73-860-I
Description:	Based on observations made during a tour of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area. EVIDENCE: 1. The door leading to the back service area was noted by the LI and staff person 2 to be propped open on the day of inspection. A spray bottle with a yellow liquid was noted sitting out on a table in the unlocked staff break room. Clorox Clean-Up spray, Shine Up Furniture Polish, Clorox Urine Remover and Granite and Stone Cleaner was noted sitting out in the unlocked laundry room.
Plan of Correction:	Environmental Service Director (EVS), Housekeeping Assistants, Maintenance Assistant, or designee will provide in-service with housekeeping/maintenance, and departments on proper storage of cleaning supplies and hazardous materials. EVS, Maintenance assistant, or designee will monitor cleaning supplies and hazardous materials daily. To be monitored by EVS and Executive Director (ED)