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 6, 2024

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 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:

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/06/2024 8:30am until 5:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 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 #:	22VAC40-73-350-B
Description:	Based on resident record reviews, the facility failed to ascertain prior to admission whether a resident was a registered sex offender. EVIDENCE: 1. The record for resident 5, admitted to the facility on 11/20/2023, has documentation that a sex offender screening was not completed until 12/21/2023. 2. The record for resident 6, admitted to the facility on 09/14/2023, has documentation that a sex offender screening was not completed until 10/18/2023.
Plan of Correction:	CRD, ED, BOM and/or designee will audit all current records to assure compliance. All new residents will have a sex offender screening completed prior to admission to the community. To be Corrected: 5/6/2024 Action Items: 1. CRD, ED and BOM will review all resident records for completed sex offender screenings. 2. BOM will upload all resident records to share drive. 3. BOM will send ED link to records with the check off form for review and approval. 4. ED will upload check off form to share drive once approved. 3. Follow up on report findings for resolution.
Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to ensure that required personal and social information was obtained for residents prior to or at the time of admission. EVIDENCE: 1. The record for resident 1, admitted to the facility on 02/06/2024, does not have documentation that a personal and social data form was completed to include all required information prior to or at the time of admission. Interview with staff person 4 on 03/06/2024 expressed that this is correct and that a personal and social data form has not been completed.
Plan of Correction:	CRD/ED/BOM and/or designee will audit all current records to assure compliance. All new residents will have personal and social information completed and entered uploaded to share drive prior to admission to the community. To be Corrected: 5/6/2024 Action Items: 1. Resident 1?s personal and social data sheet will be added to resident records. 2. CRD, ED and BOM will review all resident records for completed Personal and Social Data sheets. 3. Follow up on report findings for resolution.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review, the facility failed to ensure that uniform assessment instruments (UAI) were completed as required. EVIDENCE: 1. The UAI dated 01/22/2024 in the record for resident 1 is checked that the resident has wandering/passive behaviors and is disoriented to some spheres all of the time but the boxes indicating the type of inappropriate behaviors or spheres affected are blank. 2. The record for resident 2 has documentation that the last Annual UAI that was completed for this resident was dated 11/08/2022. In an interview with staff person 4 on 03/06/2024, staff person 4 expressed that this was correct and no subsequent UAI?s have been completed. 3. The UAI dated 11/13/2023 in the record for resident 5 is checked that the resident has aggressive, abusive disruptive behaviors but the box indicating the type of inappropriate behaviors is blank.
Plan of Correction:	DCS, ADCS and/or designee will audit active resident records to ensure a current completed UAI is present and accurate-to be monitored by DCS and ED. To be Corrected: 5/6/2024 Action Items: 1. Resident 1, 2 and 5?s charts will be corrected. 2. DCS and ADCS will review all charts for accurate and completed UAIs. 3. Corrected UAIs will be signed and placed on chart within 24 hours of corrections made. 4. Follow up on report findings for resolution.
Standard #:	22VAC40-73-450-D
Description:	Based on a review of resident records, the facility failed to ensure that all coordinated services provided by hospice and by the facility were included on the residents individualized service plans (ISPs). EVIDENCE: 1. The ISP dated 02/07/2024 in the record for resident 4 has documentation dated 09/02/2023 that the resident is receiving Hospice care but does not address any coordinated services between the facility and hospice or any hospice services that are being provided. 1. The record for resident 5 has documentation that the resident was admitted to hospice services on 11/29/2023. The ISP in the computer record for resident 5 has documentation dated 01/30/2023 that resident 5 is receiving Hospice care but does not address any coordinated services between the facility and hospice or any hospice services that are being provided.
Plan of Correction:	DCS, ADCS, and/or designee will audit active resident medical records receiving Hospice Services to ensure that comprehensive ISPs display the resident-identified needs are met via wellness team and hospice team To be Corrected: 5/6/2024 Action Items: 1. DCS, ADSCS and ED will review all charts for comprehensive ISP?s utilizing hospice services. 2. DCS will meet with each hospice provider and amend the ISP to reflect the services provided by hospice to the resident. 3. Corrected ISPs will be signed and placed on chart within 24 hour of changes made. 4. Follow up on report findings for resolution.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review, the facility failed to ensure that individualized service plans (ISP) were signed and dated by the person who developed the plan and by the resident of their legal representative. EVIDENCE: 1. The ISP dated 02/07/2024 in the record for resident 3 does not have documentation of the resident or their legal representative?s signature. A note on the ISP has documentation that ?copy sent via email to RP on 02/02/2024? but the email was unable to be located on the day of inspection to verify if and who the ISP was sent to. 2. The ISP in the computer record for resident 5 has documentation that the ISP was updated on 01/30/2024 for Falls and Hospice care. The ISP also has documentation of an update on 02/06/2024 for A DNR. The ISP does not have documentation of the signature of the person who updated the ISP or the resident or their legal representative.
Plan of Correction:	DCS, ADCS and/or designee will review all charts for comprehensive ISPs for signature of individual who completed ISP and resident and/or RP To be Corrected: 5/6/2024 Action Items: ACTION ITEMS: 1. Resident 3 and resident 5 ISPs will be corrected. 2. DCS and ED will review all charts for comprehensive ISPs for signature of individual who completed ISP and resident and/or RP. 3. Follow up on report findings for resolution.
Standard #:	22VAC40-73-560-E
Description:	Based on resident record reviews, the facility failed to ensure that resident records were kept current. EVIDENCE: 1. The record for resident 6, admitted on 09/14/2023, did not contain documentation of written acknowledgement of the resident receiving a facility disclosure statement or signed acknowledgement of the resident receiving an orientation to the facility.
Plan of Correction:	ED, BOM and/or designee will review all resident records to ensure all include signed disclosure statement and orientation acknowledgment. To be Corrected: 5/6/2024 Action Items: 1. ED, BOM and/or designee will meet with resident 6 to review and sign the community disclosure statement and orientation acknowledgement. 2. All resident records will be audited for correct disclosure statements and orientation acknowledgments. 3. BOM and ED will upload resident records to share drive. 4. Follow up on report finding for resolution.
Standard #:	22VAC40-73-560-F
Description:	Based on observations and staff interviews, the facility failed to ensure that all records were made available for inspection by the department?s representative. EVIDENCE: 1. On 03/06/2024 at 8:59am the LI supplied staff person 5 with a list of resident records that were being requested for review. This list included the record for resident 7. 2. Several additional verbal requests for the medical record for resident 7 were made by the LI to staff persons 3, 4 and 5 in the presence of the Licensing Administrator (LA) between 10:30am and 5:00pm on 03/06/2024. During the on-site exit interview conducted at 5:25pm on 03/06/2024 the LI expressed to staff person 3 in the presence of the LA that the record for resident 7 was not produced/made available on the day of inspection. Staff person 3 expressed that they had been unable to locate the medical record for resident 7.
Plan of Correction:	DCS, ADCS, and/or designee will audit all medical charts to ensure all are kept in their designated areas. To be Corrected: 5/6/2024 Action Items: 1. Resident 7 medical chart will be audited and stored in the designated area. 2. DCS and ED will audit all medical charts to ensure all are in designated areas. 3. Follow up on report finding for resolution.
Standard #:	22VAC40-73-640-A
Description:	Based on observations of the morning medication pass and review of the facility medication management plan, the facility failed to ensure implementation of the medication management plan regarding the crushing of mediations. EVIDENCE: 1. At 8:53am on 03/06/2024 the LI observed the morning medication pass on the facility memory care unit and noted that staff person 1 crushed the 9am medications for resident 7, which included the medication Metoprolol 25mg ER (extended release). 2. A review of the facility medication management plan noted that the plan has documentation that a pharmacy policy and procedure manual used by the facility is available to all wellness staff on-site for reference and review. The pharmacy policy and procedure manual has documentation on page 48 under 2.7 that The community staff may crush oral medications only in accordance with applicable law, pharmacy guidelines and/or community policy. See Appendix 11: Oral Dosage Forms That Should Not Be Crushed. Appendix 11 on page 104 has documentation that extended-release medications are a oral dosage form that should not be crushed.
Plan of Correction:	DCS, ADCS, and/or designee to complete daily audit of administration compliance, DCS to provide medication management plan in-service for RMAs and LPNs- to be monitored by DCS and ED. To be Corrected: 5/6/2024 Action Items: 1. DCS and ADCS will be educated on medication management plan. 2. DCS and ADCS will provide education on medication management plan to all LPNs and RMAs. 3. DCS AND ADCS will complete daily medication administration audit report review to assure compliance with medication management plan. 4. Follow up on report finding for resolution.
Standard #:	22VAC40-73-680-B
Description:	Based on observations of the facility medication carts, the facility failed to ensure that medications remained in the pharmacy issued container with the prescription label or direction label attached until administered to residents. EVIDENCE: 1. The LI conducted an audit of the medication cart located on the facility memory care unit on 03/06/2024 and observed in the second drawer a plastic cup labeled with ?222? with a clear liquid inside, a plastic cup labeled with ?223? with a clear liquid inside, a plastic cup with a clear liquid and a powder substance on the bottom of the cup and a plastic measured medicine cup with a pink cream substance. In an interview conducted on 03/06/2024 with staff person 1 in the presence of staff person 3, staff person 1 expressed that the 2 cups labeled with room numbers contained Miralax with water for residents 5 and 7, the cup with the powder substance contained a crushed Potassium pill and water for resident 11 and the plastic measured medicine cup contained Calmoseptine Cream for resident 2. The medications were not in the pharmacy issued containers with the prescription label attached.
Plan of Correction:	DCS, ADCS, and/or designee will audit all medication carts to assure medication management compliance with dating, storing, signing, and discarding medications per the medication management plan. Staff will receive education on the medication management plan for continued compliance. To be Corrected: 5/6/2024 Action Items: 1. DCS and ADCS will be educated on medication management plan. 2. DCS and ADCS will provide education on medication management plan to all LPNs and RMAs. 3. DCS AND ADCS will complete daily medication administration audit report review to assure compliance with medication management plan. 4. Follow up on report finding for resolution.
Standard #:	22VAC40-73-680-K
Description:	Based on resident record review, the facility failed to ensure that a detailed medication order that included symptoms to indicate the use of a PRN medication was obtained when medication aides administer PRN medications to residents. EVIDENCE: 1. The record for resident 3 has a physician order dated 01/29/2024 for Ativan 0.5mg, give 1 tablet by mouth every 8 hours as needed for anxiety. The order does not include symptoms to indicate the use of the medication when medication aides administer the medication. 2. The uniform assessment instrument (UAI) dated 08/15/2024 has documentation that resident 3 is dependent with medication administration and is disorient to all spheres some of the time. Interview with staff person 4 conducted on 03/06/2024 expressed that this is correct and that resident 3 would not be able to ask for the PRN Ativan medication. 3. The February and March 2024 medication administration record (MAR) has staff person 6?s initials for administering the PRN Ativan on 02/01/2024 and 03/03/2024. The February 2024 MAR has staff person 1?s initials for administering the PRN Ativan on 02/05/2024. Staff persons 1 and 6 are both noted to be registered medication aides.
Plan of Correction:	DCS, ADCS, and/or designee will audit all PRN medications for specific symptoms. Any necessitating an assessment, we will contact doctor to rewrite orders with specific symptoms. To be Corrected: 5/6/2024 Action Items: 1. DCS and ADCS will be educated on medication management plan. 2. LPNs and LPNs will be in-serviced on medication management plan and monitoring practices. 3. DCS and ADCS will be in-serviced on order listing report. 4. Order listing report reviewed in daily department head meeting and stand up for review of new orders. 5. DCS and ADCS will be in-serviced on medication/treatment administration audit and reports. 6. Medication/treatment administration audit report will be reviewed daily for missed entries identified missed entries will be rectified. 7. Charge nurses will be trained on utilization of clinical dashboard to identify missed entries during current shift and rectify. 8. DCS and ADCS will complete daily medication administration audit report review to assure compliance with medication management plan. 9. Follow up on report finding for resolution.
Standard #:	22VAC40-73-950-E
Description:	Based on resident record and facility documentation review, the facility failed to ensure that a review of the facility emergency preparedness and response plan was completed semi-annually with residents. EVIDENCE: 1. The semi-annual review of the facility emergency preparedness and response plan that was completed with staff on 01/16/2024 does not have documentation that the review was completed with residents. No other documentation was available for review on 03/06/2024 to show that a semi-annual review has been completed with residents.
Plan of Correction:	ED, ESD and/or designee will review all emergency preparedness and response plans monthly at Resident Council meetings. ED will include a copy to all families and residents via weekly email correspondence. To be Corrected: 5/6/2024 Action Items: 1. ED, ESD and/or designee will review emergency preparedness and response with all residents monthly at Resident Council meeting. 2. ED will include the emergency preparedness and response plan in all weekly email correspondence with families and residents. 3. ED will keep all sign in sheets from resident council meetings in binder in ED office.