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: July 25, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 07/25/2023 10:00AM until 2:45PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/27/2023 regarding allegations in the areas of: personnel, staffing and supervision, and resident care and related services. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: resident care and related services. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-280-A
Complaint related:	Yes
Description:	Based on resident record review and staff interview, the facility failed to ensure that there are staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with this chapter. EVIDENCE: 1. The record for resident 1 contains a physician?s order, dated 07/10/2023, for as needed (PRN) Epinephrine 0.3MG/0.3ML inject contents of one autoinjector into the muscle one time for allergic reaction/anaphaxylsis for throat closing, severe wheezing and shortness of breath in regard to allergic reaction. The website, www.epipen.ca/when-to-use-epipen, includes documentation that if an individual has been prescribed an EpiPen that it should be used immediately at the first signs and symptoms of a severe allergic reaction. 2. The June 2023 medication administration record (MAR) for resident 2 contains documentation that the resident has an as needed (PRN) order for ?Nitroglycerin 0.4MG tablet SL 1 Tab under tongue onset chest pain RPT every 5min X2 if no relief call MD for angina?. The manufacturer?s instructions for Nitroglycerin indicate that the medication should be administered under the tongue at the first sign of an acute anginal attack. 3. Interview with staff person 1 during on-site inspection on 07/25/2023 revealed to two licensing inspectors (LIs) that these PRN medications for residents 1 and 2 are in the facility?s medication cart. 4. Interview with staff person 2 revealed that there is only an RMA on third shift (11:00PM until 7:00AM) up to three times per week and that the RMAs on-call live 10-15 minutes away from the facility.
Plan of Correction:	The date of the inspection this complaint was addressed and was found unfounded by APS. State inspection was present and asked all pertinent questions which were answered accordingly. The two medications that were PRN in the building have been addressed. And copies of the orders were sent to our State Inspector on 7/27/23 as evidence. Our building is staffed to care for all of our residents as needed.