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: Sept. 11, 2023

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 BUILDINGS AND GROUND

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: 09/11/2023 9:00am until 1:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed:5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 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 #:	22VAC40-73-720-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that Do Not Resuscitate Orders (DNR) for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest may only be carried out when the facility has a valid written order that has been issued by the resident?s attending physician. EVIDENCE: 1. The history and physical dated 07/24/2023 in the record for resident 6 has documentation that the resident is a DNR and to please include Virginia EMS durable DNR Form. During the on-site inspection conducted on 09/11/2023, the record for resident 6 did not contain a written durable DNR form order signed by a physician. Interview with staff 6 confirmed this was accurate.
Plan of Correction:	The DCS, ADCS, or designee will audit the community to identify all residents requiring a DNR order. All identified residents will have a DNR order written, signed, and placed if absent on audit.