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: Jan. 9, 2023

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: 01/09/2023 10:35AM until 12:45PM. The inspection was conducted to follow-up on an intensive plan of correction (IPOC) that was issued to the facility on 10/13/2022 to ensure that the facility has come into compliance with previous standards cited. 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 #:	22VAC40-73-40-A
Description:	Based on licensee interview, the licensee failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department. EVIDENCE: During on-site inspection on 01/09/2023, it was confirmed through an interview with the licensee that the facility has not had a qualified administrator of record since 07/05/2022.
Plan of Correction:	I have been in contact with NAB and have looked for a temporary administrator in the meantime. Because of how rural the location of the facility it has been difficult to find one. In the meantime, I will keep moving forward in my insistence with NAB. And will notify you of any updates. Today was my latest call to them.
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 a licensed administrator of record since 07/05/2022. Interview with staff 1 confirmed this is accurate.
Plan of Correction:	Today I had a call with NAB in which they have created a new case ticket to determine when the correction in their software will be made. I will follow back tomorrow. As they stated that they would send an email to confirm were they are in the process. I did not receive this email so I will call again tomorrow.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, 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 included a physician?s order, dated 11/07/2022, for Humalog insulin 10 units sub-q three times a day for diabetes and hold if blood sugar is less than 150. The December 2022 medication administration record (MAR) for resident 1 indicated that the resident?s blood sugar was 98 at 4:00PM on 12/30/2022; however, documentation showed the aforementioned insulin was administered. 2. The record for resident 2 included a physician?s order, dated 08/09/2022, for Novolog insulin 6 units sub-q three times a day before meals for diabetes and hold if blood sugar is less than 150. The December 2022 MAR for resident 2 indicated that the resident?s blood sugar was 150 at 7:00AM on 12/03/2022 and the insulin was held when it should have been administered and the January 2023 MAR for resident 2 indicated that the resident?s blood sugar was 111 at 7:00AM on 01/05/2023 and 137 at 4:00PM on 01/05/2023; however, documentation showed the aforementioned insulin was administered. The record for resident 3 included a physician?s order, dated 10/31/2022, for Novolog insulin 5 units sub-q three times a day and hold if blood sugar is less than 150. The December 2022 MAR for resident 3 included multiple days between 12/01/2022 through 12/19/2022 that the aforementioned insulin had been administered to the resident at 7:00AM and 4:00PM and on 12/19/2022 at 11:00AM; however, the MAR did not include documentation of what the resident?s blood sugar reading was to indicate if the insulin should have been administered or held.
Plan of Correction:	We have reviewed all Med orders and had the physician go through the Med management with the staff. Explain the importance of the scale. And when exactly this should be given and why. The exact sugar readings the resident must have in order to receive or not the insulin. Once again we have almost restrained this Med-Aide from passing Meds. Until the new Med Aide trainees are able to pass them.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to ensure medication administration records (MARs) included all required components. EVIDENCE: 1. The December 2022 MAR for resident 1 did not indicate that the following 7:00AM medications and treatments had been administered to the resident on 12/30/2022: Amlodipine Besylate 5MG, Aspirin 81MG, blood pressure check, blood sugar test, Duloxetine HCL DR 30MG, Humalog 10 units, HCTZ 12.5MG, Levemir 7 units, Magnesium Oxide 400MG, Metformin 1,000MG, Metoprolol Tartrate 50MG, Omeprazole 20MG, Polyethylene, and Vitamin D3. The December 2022 MAR also did not include that the following 7:00PM medications had been administered to the resident on 12/23/2022 and 12/31/2022: Levemir 7 units, Metoprolol Tartrate 50MG, Polyethylene, Topiramate 25MG, and Simvastatin 10MG. 2. The December 2022 MAR for resident 2 did not indicate that the scheduled 4:00PM Novolog 6 units had been administered to the resident on 12/14/2022 and the scheduled 7:00PM Simvastatin 20MG had been administered to the resident on 12/23/2022. 3. The December 2022 MAR for resident 3 did not indicate that the following 7:00PM medications had been administered to the resident on 12/23/2022: Aspirin 81MG, Buspirone HCL 10MG, Divalproex 500MG, Eucerin lotion, Mucinex 600MG, Levemir 45 units, Magnesium Oxide 400MG, Melatonin 3MG, Mirtazapine 30MG, Simvastatin 40MG, and Vitamin C. The December 2022 MAR also did not indicate that the following 4:00PM medication had been administered to the resident on 12/30/2022: Novolog 5 units.
Plan of Correction:	The following errors were made by a Med-Aide that has already been basically removed from the med cart. Having other staff members leave later in the afternoon for the last med pass of the day. And having the morning Med-Aide come in earlier to pass the first meds. Thus, restricting the Med-Aide in question from passing meds to as little as possible. This Med-Aide has already done 2 refresher courses. And we have 3 new Med-Aides finishing the coarse so that we may fully replace her. That giving us the ability to fill in the place of the current Med-Aide. We are still checking weekly all med passes in our records. But will begin to do so three times a week. We want to ensure that we are checking more often.