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: Sept. 26, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 09/26/2022 11:15AM until 1:15PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-150-A
Description:	Based on staff interview, the facility failed to ensure to have an administrator of record. EVIDENCE: The facility has not had an administrator of record since 07/05/2022. Interview with staff 4 confirmed this is accurate.
Plan of Correction:	I have submitted all required documentation in which yesterday I have received two corrections to do. These corrections have been immediately remedied. And I should be expecting an answer soon. I have established a solid communication chain with the new Board of Long-Term person in charge. This has given me the opportunity to be aware of the status of my application. After these two corrections are accepted, I should be expecting the green to be able to take the exam. All communication shall be shared with Jennifer Stokes so that she is aware as well of all process standings.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and staff interview, the facility failed to ensure that 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 04/01/2022, for Humalog three times a day for diabetes and hold if blood sugar is less than 150. The September 2022 medication administration record (MAR) for resident 1 indicates that the resident was administered Humalog on 09/09/2022 at 4:00PM by staff 1; however, the recorded blood glucose by staff 1 for the resident was 148 and therefore Humalog should have been held. The record for resident 1 contained a physician?s order for Amlodipine Besylate 5MG tablet take one every morning for blood pressure and hold for systolic blood pressure (top number) less than 100. The September 2022 MAR for resident 1 indicates that staff 2 administered Amlodipine Besylate on 09/12/2022 at 7:00AM to resident 1; however, the resident?s blood pressure reading was documented by staff 3 as 95/54 and should have been held.
Plan of Correction:	The following has been discussed with the staff and we will have them look at their notes and medication administrations directly after every pass to make sure that all medications are checked off. Making the margin of error minimal.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to ensure the medication administration record included all required components. EVIDENCE: The September 2022 medication administration record (MAR) for resident 1 did not indicate that the resident?s scheduled 4:00PM Humalog 10 Units and Metformin HCL 500MG had been administered to the resident on 09/16/2022.
Plan of Correction:	This standard will be corrected by making sure once again that their passes are checked by them after every med pass. That all information is correct for every patient. These corrections should be in place and made a habit to ensure that errors are corrected. And leads will conduct randomized checks of med charts for all residents to make sure there are no mistakes made.