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: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

Type of inspection: Monitoring Date(s) 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. 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 #:	22VAC40-73-250-D
Description:	Based on staff record review and staff interview, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility submitted the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or form consistent with it. EVIDENCE: The record for staff person 2, date of hire 06/01/2023, did not contain the results of a risk assessment documenting the absence of TB. Interview with staff person 2 confirmed that this is accurate.
Plan of Correction:	The TB screen test has been completed 7/26/23
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that a physical examination with all required information was obtained within 30 days prior to a resident?s admission. EVIDENCE: 1. During an on-site inspection that was conducted on 05/30/2023, the physical exam in the record for resident 1 was noted to lack documentation of the resident?s address, phone number, height, weight, blood pressure, significant medical history, a statement as to the resident?s ambulatory/non-ambulatory status, a statement as to the resident?s ability/inability to self-administer medications, a statement that the individual does not have any conditions or care needs that are prohibited by 22VAC40-73-310-H, medications, diet and therapy recommendations if any. 2. During this on-site inspection conducted on 07/25/2023, the LI was unable to locate the 03/07/2023 physical examination in the record for resident 1. In an interview with staff persons 2 and 5, it was expressed by staff person 5 that resident 1?s physician was in the process of updating/completing the physical examination that was originally conducted on 03/07/2023. Staff person 5 later produced the 03/07/2023 physical examination which was completed by collateral 3 and dated for 07/25/2023, the date of this inspection. Resident 1?s height, weight and blood pressure were noted to still be missing from the physical examination form.
Plan of Correction:	The original physical was in the residents file on 7/25/223. The physical being transferred to the VA format arrived on the same day of the inspection as it was requested to be expedited. And as it was missing the weight, height, blood pressure, address and phone number. This was corrected that same day as well.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to ensure that individualized service plans (ISPs) were reviewed and updated at least annually. EVIDENCE: The ISP in the record for resident 8 has documentation that it was last reviewed/updated on 04/05/2022.
Plan of Correction:	The administrative office is working diligently to update all ISPs.
Standard #:	22VAC40-73-640-A
Description:	Based on observations of the facility?s medication carts, document review, resident record review, and staff interview, the facility failed to ensure to implement portions of its medication management plan (MMP) and that it contained all required components. EVIDENCE: 1. The facility?s medication management plan has documentation that ?All medication carts will be checked on a weekly basis by the lead RMA for expiration dates, damage, tampering or contamination?. 2. The bottom medication cart contained an opened vial of Novolog Insulin in the cart for resident 5. The vial did not contain a date that it was opened to ensure that the insulin is disposed of within 28 days of opening per manufacturer instructions. 3. The Bottom medication cart contained an opened Lantus Solostar Insulin pen in the cart for resident 9. The pen did not contain a date that it was opened to ensure that the insulin is disposed of within 28 days of opening per manufacturer instructions. 4. The Top medication cart contained an opened vial of Insulin Glargine in the cart for resident 10. The vial did not contain a date that it was opened to ensure that the insulin is disposed of within 28 days of opening per manufacturer instructions. 5. During an interview with staff 5 during on-site inspection, it was expressed that there is not a staff person on-site to administer medications on the 11:00PM to 7:00AM shift for some days. The facility?s MMP does not indicate their standard operating procedures for ensuring that medication administration is available on shifts when a medication staff person is not on duty in the building.
Plan of Correction:	The lead RMA does check our carts on a weekly basis. All insulin has stated to be dated before opening and disbursement of medication. Upon our interview our building explained our procedures for Medication management when there is not a RMA on staff. We are currently updating MMP to state the procedure for our building. Our on-call RMA lives within 10 mins of the facility. And our other RMAs live 10-17 mins away.
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 3 contains a physician?s order, dated 04/05/2023, for Novolog 6 units three times daily before meals for diabetes, hold if the resident?s blood sugar is less than 150. 2. The July 2023 medication administration record (MAR) for resident 3 indicates that at 7:00AM on 07/18/2023 the resident?s blood sugar was 138; however, the resident was administered Novolog by staff 4 when the medication should have been held.
Plan of Correction:	Med-Tech Staff has been given a refresher on patient medication dosages and their management.
Standard #:	22VAC40-73-870-B
Description:	Based on observations of the facility physical plant, the facility failed to keep the building well-ventilated and free from foul, stale, musty odors. EVIDENCE: The bathroom in room 121 was noted to have a strong urine odor on the day of inspection.
Plan of Correction:	The Bathroom floor has been replaced completely.
Standard #:	22VAC40-73-870-E
Description:	Based on observations of the facility physical plant, the facility failed to ensure that all furnishings and fixtures were maintained in good repair. EVIDENCE: The window covering in room 115 was noted to be broken and missing several blinds on the day of inspection.
Plan of Correction:	The 2 vertical blinds that were missing have been replaced.
Standard #:	22VAC40-73-990-C
Description:	Based on review of facility documentation and staff interview, the facility failed to ensure that at least once every six months all staff currently on duty on each shift participated in an exercise in which the procedures for resident emergencies were practiced and documentation of each exercise was maintained in the facility for at least two years. EVIDENCE: During an on-site inspection conducted on 07/25/2023, staff person 2 was unable to provide evidence that a six-month practice of the facility?s procedures for resident emergencies was completed with staff currently on duty on each shift. Staff person 2 expressed that this has not been completed as of the day of this inspection.
Plan of Correction:	This has been corrected and will be an on-going practice.