VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Friendship Assisted Living, Inc.
320 Hershberger Road
Roanoke, VA 24012
(540) 265-2244

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: April 27, 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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 04/27/2023 from 09:00 AM until 02:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-200-B
Description:	Based on resident record review, the facility failed to ensure that direct care staff who are responsible for caring for residents with special health care needs only provide services within the scope of their practice and training. EVIDENCE: 1. The record for resident 10 contains a physician?s order, dated 01/15/2023, for the following: ?Cleanse lesion to right side of face (post skin cancer removal) with soap and water, pat dry, apply Vaseline ointment using a q-tip and cover with non-stick dressing or band-aid Change dressing one time daily *start on 1/21/23 48 hours post skin cancer removal* every day shift for treatment of lesion s/p skin cancer removal until healed?. 2. Interview with staff person 7 revealed that the resident?s incision area regarding the skin cancer removal contained sutures. 3. The January 2023, February 2023, March 2023, and April 2023 medication administration records (MARs) for resident 10 contain initials of registered medication aides (RMAs) numerous days each month as providing the aforementioned treatment to the resident?s wound; however, providing wound treatment is out of an RMA?s scope of practice.
Plan of Correction:	Educate all RMA?s/LPN?s on their scope of practice. Enhabit Home Health and Hospice will provide updated Wound/Lesion Care In-Service to all Licensed staff. Will update all Wound/Lesion treatments to assign: LPN will do. DON and ADON will complete random audits of all new treatment orders and ensure assignment of treatments.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 8, dated 10/14/2022, indicates that the resident requires physical assistance with walking and wheeling. 2. An interview with staff 7 confirmed that this is correct; however, the ISP for resident 8, dated 10/14/2022, does not address these identified needs.
Plan of Correction:	Sonja Johnson, ADON updated/corrected ISP on 4/27/23. Kim Novak, LPN will continue to provide Healthcare Oversight and will complete random audits. Ashley Davis, LPN will continue ISP random audits.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, staff interview, and policy review, the facility failed to implement a part of its medication management plan regarding methods to prevent the use of outdated, damaged, or contaminated medications. EVIDENCE: 1. The facility?s medication management plan, updated 08/26/2022, states that routine medication pass observations and medication cart audits will be conducted by an individual working within their scope of practice, to include all medication administration staff, to ensure conformance of the medication management plan. The plan further states that medication cart audits include observation for any expired, damaged, contaminated, or discontinued medications. 2. On the date of inspection, LI completed an audit of the 2nd floor medication cart-A. At that time, LI observed a Novolog Flex Pen prefilled syringe that appeared to have been opened as the plunger was down near the bottom of the pen; however, there was no open date on the unit to ensure that the Novolog Flex Pen prefilled syringe will be discarded 28 days after opening per manufacturer?s instructions. 3. Upon interviewing staff 6 during the cart audit, staff 6 stated that she could determine that the Novolog Flex Pen prefilled syringe had been opened/used based on its appearance, but she could not be certain when it was opened because there was no open date indicated; therefore, she was not able to determine when to discard the pen.
Plan of Correction:	Discarded Novolog Flex Pen on this date 4/27/23. DON and ADON will provide education to add Open Date and Expiration Date on all insulin pens. DON and ADON will do random audits to check for Open Date and Expiration Date on all open pens.
Standard #:	22VAC40-73-680-D
Description:	Based on observation of a medication pass, observation during an audit of a medication cart, and resident record review, the facility failed to ensure that a medication was administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 10 contains a physician?s order, dated 03/07/2023, to decrease Lasix (Furosemide) to 10 MG once a day ?half 20MG to Equal 10MG?. 2. The March 2023 medication administration record (MAR) (starting 03/08/2023) and the April 2023 MAR for the resident includes Lasix Tablet 20 MG (Furosemide) give 0.5 tablet by mouth in the morning for edema - take half of 20 MG to equal 10 MG. The description of Lasix (Furosemide) 20 MG tablet that is located on the packaging for resident 10?s medications stated that Furosemide 20MG is a ?tablet round, white txt: ep:116? and the tablet located in the packaging was whole. This was also noted by staff persons 2 and 6 and collaterals 1 and 2 during the medication cart audit that contains resident 10?s medications. 3. Collateral 1 noted during observation of resident 10?s morning medication pass during on-site inspection on 04/27/2023 that staff 9 did not cut the Lasix (Furosemide) 20MG tablet in half therefore the resident received a whole Lasix (Furosemide) 20MG tablet.
Plan of Correction:	Pharmacist will start auditing and compare medication orders to PCC and compare to bubble pack bingo card packaging prior to delivery. Will provide education to all licensed staff (LPN?s and RMA?s) to ensure proper medication administration. Will provide in-service to all staff on Medication Management Policy.
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the physical plant, the facility failed to ensure that hazardous materials were stored in a locked area. EVIDENCE: At approximately 10:07AM during the on-site inspection, collateral 1 observed a small round dark red pill on the floor in the hallway outside of room 402. The pill was also observed by staff 4.
Plan of Correction:	In-Service for all LPN?s and RMA?s to ensure all medications are taken by each resident as appropriate.
Standard #:	22VAC40-73-870-E
Description:	Based on observations of the facility?s physical plant, the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. EVIDENCE: The mini blinds on the window in room 312 were noted to have several panels that were broken off and lying on the windowsill.
Plan of Correction:	Place work order for Maintenance to replace all missing blinds on 4/27/23.