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: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint 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 until 2:00pm 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 08/10/2022 regarding allegations in the area(s) of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 86 Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. 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 #:	22VAC40-73-680-E
Complaint related:	Yes
Description:	Based on a review of resident records and interviews with staff, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber was provided according to instructions and documented. EVIDENCE: 1. The progress notes for resident 1 has documentation dated 08/06/2022 at 7:55 that ?resident noted with skin tear to right upper arm, area cleansed with normal saline and dpd applied. Dr. to evaluate and updated order?. 2. A nursing fax communication form dated 08/06/2022 in the record for resident 1 has ?skin tear noted to right upper arm, area cleansed with normal saline xeroform applied, covered with non-adherent dssg, held in place by tubi-grip. This nursing fax communication form was noted and signed by the physician on 08/09/20222 with orders to continue with above treatment and monitor. 3. A facility incident report form was received on 08/11/2022 in regards to resident 1. The incident report has documentation ?received communication of skin tear on 08/11/2022. Skin tear assessed by director of clinical services. Dressing noted in place at time of assessment?. 4. Interviews with staff persons 2 and 3 expressed that they were both made aware of the skin tear on resident 1?s right upper arm on 08/11/2022. Per staff persons 2 and 3, contact was made with resident 1?s physician and treatment orders were confirmed. 5. The August 2022 medication administration record (MAR) for resident 1 has documentation that a daily treatment for the skin tear to the resident?s right upper arm was not started until 08/11/2022. The August 2022 MAR also does not have staff initials for the treatment being completed on 08/16/2022 and 08/17/2022.
Plan of Correction:	Provide medication management plan in-service for all RMAs and LPNs. Director of Clinical Services (DCS), Director of Clinical Inspiritas and Engagement (DCISE), or designee to complete daily audit of medication administration compliance. To be monitored by DCS, DCISE, or designee.