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: Nov. 29, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 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

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/29/2023 8:30am to 2:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 32 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standards or law, and violations 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 violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards 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 Angela Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-F
Description:	Based on record review and staff interview, the facility failed to ensure that when adults with mental impairments reside in the facility, at least four of the required training hours for direct care staff shall focus on topics related to residents' mental impairments. EVIDENCE: 1.The record for staff 1 contained a Record of Staff Training and Education Following Employment for dates 12/1/2021 to 12/1/2022 form which documented one hour of training focused on mental impairments. During an interview with two Licensing Inspectors (LIs), staff 2 confirmed the amount of training hours for staff 1 was accurate.
Plan of Correction:	Staff will have training to complete the 3 hrs. missing by Monday of next week.
Standard #:	22VAC40-73-325-A
Description:	Based on a review of resident records, the facility failed to ensure that a fall risk rating was completed by the time the comprehensive Individual Service Plan (ISP) was completed. EVIDENCE: The record for resident 1, who is assessed as assisted living level of care on their uniform assessment instrument (UAI) dated 7/24/2023, has a completed comprehensive ISP dated 7/24/2023 in the record. The record for resident 1 did not contain documentation of the date the fall risk rating was completed.
Plan of Correction:	Fall Risk documentation was found and placed in residents chart.
Standard #:	22VAC40-73-440-A
Description:	Based on review of resident records and staff interview, the facility failed to ensure that the Uniform Assessment Instrument (UAI) shall be completed at least annually for each resident. EVIDENCE: 1. The UAI dated 04/09/2023 in the record for resident 3 has documentation that the resident does not require any help with dressing, toileting, transferring, bowel incontinence, walking or mobility. In interviews conducted with staff 2 and 5 on the day of inspection, it was expressed that resident 3 does require assistance with dressing, toileting, transferring, bowel incontinence, walking and mobility. The UAI dated 04/09/2023 in the record for resident 3 has not been updated to reflect the assistance that the resident needs. 2.On the date of inspection, the record for resident 2 contained a UAI dated 9/5/2022. During an interview with two Licensing Inspectors (LIs), staff 2 confirmed the UAI in the record for resident 2 was the last UAI completed. 3.On the date of inspection, the record for resident 5 contained a UAI dated 2/16/2022. During an interview with two LIs, staff 2 confirmed the UAI in the record for resident 5 was the last UAI completed. 4.On the date of inspection, the record for resident 6, admission date of 9/10/2022, did not contain documentation of a UAI. During an interview with two LIs, staff 2 confirmed there was not a UAI in the record for resident 6
Plan of Correction:	All UAIs have been updated.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure that comprehensive individualized service plans (ISP) contained all identified needs and services to be provided for residents and shall be completed within 30 days after admission. EVIDENCE: 1.The uniform assessment instrument (UAI) dated 03/06/2023 in the record for resident 4, admitted on 03/06/2023, has documentation that the resident?s behavior pattern is abusive, aggressive, disruptive less than weekly. Observation notes in the record for resident 4 has documentation on 09/18/2023 that resident 4 took their lighter out of their pocket and stated ?I will set you on fire and if I can?t set you on fire than I will burn this building down?. On 09/26/2023 the observation notes in resident 4?s record has documentation that resident 4 locked their self in the closet. The comprehensive ISP dated 03/06/2023 does not have documentation of resident 4?s behavior patterns or of services to be provided. 2.The record for resident 1, date of admission 4/10/2023, contained a comprehensive ISP dated 7/24/2023. During an interview with two Licensing Inspectors, staff 5 confirmed there was no documentation in the record for resident 1 for the comprehensive ISP being completed within 30 days after admission.
Plan of Correction:	We are in the process of correcting this and it will be done by the 18th of this month.
Standard #:	22VAC40-73-450-D
Description:	Based on resident record review and staff interview, the facility failed to ensure that when hospice services are provided to a resident that the services provided are included on the residents individualized service plan (ISP). EVIDENCE: 1. The record for resident 3 has documentation that the resident was admitted to hospice services on 10/04/2023. Interviews conducted with staff 2 and 5 on the day of inspection confirmed that this was accurate. The ISP in the record for resident 3 does not include that identified need for hospice or the services that the hospice is providing.
Plan of Correction:	This has been corrected. And all hospice are included.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review, the facility failed to ensure that individualized service plans (ISP) were signed and dated by the licensee, administrator or their designee, (i.e, the person who has developed the plan). EVIDENCE: 1. The record for resident 3 has an ISP that has the date ID listed as 04/09/2023 for resident 3?s identified needs but the ISP does not have the signature of the person who completed the plan or the date that is was completed.
Plan of Correction:	As a facility we have that all ISPs are signed by the person responsible.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and staff interviews, the facility failed to ensure that individualized service plans (ISP) are reviewed and updated at least once every 12 months and as needed for a significant change in a resident?s condition. EVIDENCE: 1.On the date of inspection, the record for resident 2 contained the current ISP dated 7/1/2021. During an interview with two Licensing Inspectors (LIs), staff person 2 confirmed the ISP in the record for resident 2 was the current ISP. 2.On the date of inspection, the record for resident 5 contained the current ISP dated 2/16/2022. During an interview with two LIs, staff person 2 confirmed the ISP in the record for resident 5 was the current ISP. 3.The record for resident 3 has documentation that the resident has a do not resuscitate order signed 08/25/2021. The ISP has not been updated to reflect this identified need as it has that resident 3 is a full code identified on 04/09/2023. 4.In interviews conducted with staff 2 and 5 on the day of inspection, it was expressed that resident 3 requires assistance with dressing, toileting, transferring, bowel incontinence, walking and mobility. The ISP in the record for resident 3 has not been updated to reflect these identified needs.
Plan of Correction:	We as a facility have begun to review all ISPs and ensure that they are updated in a timely manner.