VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Red Oak Manor
18360 Virgil Goode Hwy
Rocky mount, VA 24151

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: Feb. 3, 2022

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 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.

Technical Assistance:

To ensure that the facility had a thorough understanding of the standards, the licensing inspectors had a discussion with the licensee regarding standards 260-A, 380-A, 610-E, 860-D and 970-A.

Comments:

The licensing inspector (LI) for Red Oak Manor, along with another LI, conducted an unannounced renewal study on 02/03/2022 from 8:05am until 3:38pm, finding 43 residents in care. The inspection included a tour of the physical plant, observation of a medication pass, review of the medication storage carts, and resident interviews. Eight resident records were thoroughly reviewed, and an additional 4 were partially reviewed in relation to the observation of the medication pass. Sworn disclosure statements and criminal record checks were examined for all staff and the records of three staff were thoroughly examined. Additional facility documentation was surveyed for compliance with the Standards for Assisted Living Facilities. Findings were reviewed with the licensee during the inspection. An exit interview was conducted with the licensee and the direct care staff member in charge on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 309-2796.

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on observation, the facility failed to ensure that infection control policies that are consistent with CDC recommendations were followed. EVIDENCE: The cart that is used for storage of glucometers that is located in the facility?s medication room contained three glucometer bags that were labeled for residents 2, 9 and 10 on the day of inspection. The meters that were located inside of each bag were not labeled with the resident?s name per CDC recommendations.
Plan of Correction:	All glucometers were labeled immediately reviewed medication management plan on 2/3/2022.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review, the facility failed to ensure that for private pay individuals, the assisted living facility shall ensure that the uniform assessment instrument (UAI) is completed as required. EVIDENCE: The UAI for resident 6, dated 1/4/2022, indicated that the resident has bladder incontinence; however, the UAI did not specify the type of help needed. In addition, the same UAI for resident 6 was not completed under the Medication Administration and Behavior Pattern sections.
Plan of Correction:	UAI was reviewed with assessor updated made to the corrected all missing information.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to ensure that individualized service plans (ISP) were reviewed and updated as the condition of a resident changes. EVIDENCE: 1. The record for resident 3 contained a physician?s order, dated 12/20/2021, for the resident to be evaluated for physical therapy. Interview with staff 4 confirmed that the resident has been receiving physical therapy services. The ISP for resident 3, dated 12/27/2021, did not contain documentation that the resident is receiving physical therapy services. 2. The uniform assessment instrument (UAI), dated 12/27/2021, for resident 3 showed that the resident needs physical human help with transferring. The ISP, dated 12/27/2021, for the resident showed that the resident needs mechanical help and physical human help with transferring. Interview with staff 5 revealed that the UAI is correct and the ISP is incorrect.
Plan of Correction:	ISP updated to include PT services and transferring assistance on 2/9/2022
Standard #:	22VAC40-73-640-A
Description:	Based on document review, the facility failed to implement their medication management plan. EVIDENCE: 1. The document ?Red Oak Manor Assisted Living Medication Management Plan Revised 2021? stated the following: ?All medication carts Will be checked on a weekly basis by the charge medication technician for expiration dates, damage, tampering, or contamination. If any medication is found to be expired, damage, show signs of tampering, or appear [sic] to be contaminated, it shall be documented in the nurses notes for the residents, and for the shift. The administrator and the pharmacy shall be informed, verbally or in writing. The medication shall be disposed of according to a facility policy or in accordance with the pharmacy instructions.? The Top Hall medication cart contained two bottles of nitroglycerin; one bottle for resident 1 and one bottle for resident 8. The manufacturer expiration date of each bottle was 09/2021. Both residents 1 and 8 contained a physician?s order for nitroglycerin. 2. The document also stated the following: ?At the end of each shift, and the beginning of another shift, the two medication technicians Will perform a count of all controlled medication in the locked drawers, to ensure all control medications given on the shift has been correctly documented. Discount [sic] will also be documented every shift.? The ?Red Oak Manor Control Sheet? for top cart and bottom cart contained multiple dates that were not signed by either the incoming medication aide or the outgoing medication aide to confirm that a count of the controlled medications had been performed.
Plan of Correction:	1. Removed Nitro immediately ordered new. Reviewed with RMA's doing cart audit to check bottle also not just box. 2. Reviewed with RMA's to ensure they are signing count log correctly. 3. Reviewed medication management plan on 2/7/2022.
Standard #:	22VAC40-73-650-A
Description:	Based on resident record review, the facility failed to ensure that no medication, dietary supplement, or treatment was changed or discontinued without a valid order from a physician or other prescriber. EVIDENCE: At approximately 11:08 AM, one licensing inspector observed the following topical powder in resident 11?s room: ?Miconazole Nitrate 2% top pwdr ? a small amount topically twice a day to right arm?. Interview with staff 1 revealed that the resident does keep this in her room. The record for resident 11 did not contain a physician?s order that the resident can keep this at bedside and administer on her own.
Plan of Correction:	Miconaozole removed from room immediately on 2/3/22. Obtained orders on 2/10/2022. Medication will be kept in med cart and administered by RMA/LPN/RN.
Standard #:	22VAC40-73-680-H
Description:	Based on documentation review, the facility failed to document on a medication administration record (MAR) all medications administered to residents at the time the medication was administered. EVIDENCE: 1. The February 2022 MAR?s for the following residents that were administered medications did not include documentation of the staff or the date and time on the MARs that the medications had been administered: Resident 12: Ziprasidone 20MG at 12PM and Ziprasidone HCL 80MG at 5PM on 02/01/2022 and Zinc Gluconate 50MG at 7AM on 02/01-03/2022; Resident 3: Oyster Shell Calcium 500MG at 12PM on 02/01/2022; Resident 10: Gabapentin 400MG at 2PM on 02/01/2022; Resident 11: Aspirin 81MG at 7AM on 02/02/2022 and 02/03/2022; Resident 13: Metformin HCL ER 500MG at 4PM on 02/01/2022 and Resident 14: Diclofenac Sodium 1% gel and Gabapentin 300 MG at 2PM on 02/01/2022.
Plan of Correction:	RMAs educated on ensuring MAR is signed off. Medication Management plan was reviewed on 2/5/2022.
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to ensure a valid physician?s order for oxygen contained all the required components. EVIDENCE: 1. The record for resident 4 contained a physician?s order, dated 01/04/2022, that showed ?Oxygen sig: 2 litters [sic] oxygen via nasal cannula with rest? and ?Oxygen sig: 4 liters oxygen via nasal cannula with exertion?. The orders did not contain the oxygen source. 2. The records for resident 2 and 5 contained physician's orders, dated 01/04/2022, for oxygen; however the orders did not contain the oxygen source.
Plan of Correction:	1) Received updated orders on 2/10/22 to reflect source updated on MAR. 2) Received updated orders on 2/10/22 to reflect source updated on MAR.
Standard #:	22VAC40-73-720-A
Description:	Based on resident record review, the facility failed to ensure that the written do not resuscitate order (DNR) was included on the individualized service plan (ISP). EVIDENCE: 1. Interview with staff 5 confirmed that resident 4 has a DNR order. The ISP for the resident, dated 08/16/2021, did not contain documentation that the resident has a DNR order.
Plan of Correction:	ISP for 5 updated to include DNR
Standard #:	22VAC40-73-860-I
Description:	Based on observation and staff interview, the facility failed to ensure that each facility shall store cleaning supplies and other hazardous materials in a locked area. EVIDENCE: 1. While performing the physical plant tour on the date of inspection, collateral 1 observed a storage closet which contained a sign on the door that stated ?Storage ? Authorized Persons Only ? This Room is to remain locked at all times?. Collateral 1 observed that the padlock on the storage closet door was in the unlocked position, and when collateral 1 turned the doorknob, the closet door opened revealing numerous housekeeping supplies inside. These include: Member?s Mark dryer sheets, Husky drawstring trash bags, Fabuloso cleaner, Softsoap liquid hand soap, Lysol disinfectant, carpet and room deodorizer, Dermasil lotion, Clorox urine remover, Pledge furniture polish, Comet cleanser, Microban sanitizing spray and cleaner, glass cleaner, Isopropyl Alcohol, OdoBan spray, Germ-X hand sanitizer, ColorPlace white latex caulk, Rust-Oleum protectant, and wood screws. 2. Interview with staff 5 verified that the facility contains a mixed population.
Plan of Correction:	Door handle/lock changed on 2/9/2022 Reviewed with team to ensure door is locked at all times.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee. EVIDENCE: The record for staff 4 indicated a hire date of 12/1/2021; however, the criminal history record report was completed on 1/5/2022.
Plan of Correction:	Administrator will ensure CHRR is back before employee starts.