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: Feb. 1, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

A complaint was received by VDSS Division of Licensing on 1.9.2024 regarding allegations in the areas of: Personnel, Staffing and Supervision, Admission, Retention, and Discharge of Residents and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 33 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation areas of non-compliance with standards or law were: Admission, Retention, and Discharge of Residents and 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 A Marie Swink, Licensing Inspector at 276-635-6575 or by email at angela.swink@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-A
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure that a physical examination with all required information was obtained within 30 days preceding admission for a resident. EVIDENCE: 1. The record for resident 1, admitted to the facility on 12/21/2023, has documentation of a physical examination dated for 12/05/2023. The physical examination does not have documentation of the required information that includes recommendations for care including diet, results of a risk assessment documenting the absence of tuberculosis, a statement that the individual does not have any conditions or care needs prohibited by 22VAC40-73-310H, a statement that specifies whether the individual is considered to be ambulatory or non - ambulatory, and a statement that specifies whether the individual is or is not capable of self-administering medication. The physical examination noted the diet as NPO (nothing by mouth) but does not provide physician?s orders for the type of nourishment the resident is supposed to receive.
Plan of Correction:	As a facility we have made a priority to send the official VA REPORT OF RESIDENT PHYSICAL EXAMINATION. As we have learned that the Primary Care Physician and Hospitals do not provide a H&P that meets this regulation. Therefore we have established to send them the original form and encourage them to please fill out this form instead of their facility established form. We will insist on this being completed.
Standard #:	22VAC40-73-650-E
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure the resident?s record contained the physician?s or other prescriber?s signed written order or a dated notation of the physician?s or other prescriber?s oral order. EVIDENCE: 1.The record for resident 1 contained an physical examination dated 12/5/2023 that included the following physician?s orders: acetaminophen 1000mg, oral, three times daily; aspirin EC 81 mg PO TbEC one tablet daily; bisacodyl EC 10mgm oral, daily as needed; Cholecalciferol 400 units, daily; Diltiazem 360mg capsule, sustained action 24HR, 1 capsule by mouth daily; Gabapentin 400mg, Oral, 3 times daily; Lidocaine 4% Adhesive Patch, Medicated, 1 patch transdermal every 24 hours as needed; Lisinopril 20mg, take 1 tablet by mouth daily; Meclizine 25mg, oral, two times daily as needed; Melatonin 5mg, Oral, Every night at bedtime as needed; Oxycodone 5mg, Oral, every 6 hours as needed; Pantoprazole 40mg, Oral, Daily; Polyethylene glycol, 17mg, Oral, every morning; and Therapeutic multivitamin ? minerals, 1 tablet, every morning. 2.A subsequent physical examination dated 12/27/2023 in the record for resident 1 has physician?s orders for the following medications: Percocet 7.5 every 6 hours as needed; Melatonin 6mg, at bedtime; Aspirin 81mg daily; Diltiazem 360mg daily; Protonix40mg daily; and Vitamin D3 400 IU daily. 3. During an on-site inspection on 2/1/2024, the record for resident 1 did not contain any documentation of physician?s orders for the discontinuation of the following medications, from the 12/5/2023 physical examination, acetaminophen 1000mg, oral, three times daily; Gabapentin 400mg, Oral, 3 times daily; Lidocaine 4% Adhesive Patch, Medicated, 1 patch transdermal every 24 hours as needed; Lisinopril 20mg, take 1 tablet by mouth daily; Meclizine 25mg, oral, two times daily as needed; Polyethylene glycol, 17mg, Oral, every morning; and Therapeutic multivitamin ? minerals, 1 tablet, every morning.
Plan of Correction:	The facility has established that all residents must have their medication orders submitted to pharmacy upon arrival to facility. To ensure that all new residents have available the medications that are prescribed to them moving forward
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1.The record for resident 1, admitted on 12/ 21/2023, has a physical examination dated 12/05/2023 with physician?s orders for the following medications: acetaminophen 1000mg, oral, three times daily; aspirin EC 81 mg PO TbEC one tablet daily; bisacodyl EC 10mgm oral, daily as needed; Cholecalciferol 400 units, daily; Diltiazem 360mg capsule, sustained action 24HR, 1 capsule by mouth daily; Gabapentin 400mg, Oral, 3 times daily; Lidocaine 4% Adhesive Patch, Medicated, 1 patch transdermal every 24 hours as needed; Lisinopril 20mg, take 1 tablet by mouth daily; Meclizine 25mg, oral, two times daily as needed; Melatonin 5mg, Oral, Every night at bedtime as needed; Oxycodone 5mg, Oral, every 6 hours as needed; Pantoprazole 40mg, Oral, Daily; Polyethylene glycol, 17mg, Oral, every morning; and Therapeutic multivitamin ? minerals, 1 tablet, every morning. 2.A subsequent physical examination dated 12/27/2023 in the record for resident 1 has physician?s orders for the following medications: Percocet 7.5 every 6 hours as needed; Melatonin 6mg, at bedtime; Aspirin 81mg daily; Diltiazem 360mg daily; Protonix40mg daily; and Vitamin D3 400 IU daily. 3.The December 2023 Medication Administration Record (MAR) in the record for resident 1 did not have staff initials to indicate that resident 1 received any medications from his date of admission on 12/21/2023 until 12/30/2023. 4.During the on-site inspection on 2/1/2024, an interview conducted with one Licensing Inspector and staff person 1, staff person 1 revealed that the resident did not receive any medications until 12/30/2023.
Plan of Correction:	The facility has established that all residents must have their medication orders submitted to pharmacy upon arrival to facility. To ensure that all new resident have the medications that are prescribed to them.