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 30, 2024

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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/30/2024 from 09:00 AM until 03:15 PM 05/01/2024 from 08:15 AM until 12:00 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 #:	22VAC40-73-680-B
Description:	Based on record review and staff interview, the facility failed to ensure that medications shall remain in the pharmacy issued container, with the prescription label attached, until administered to the resident. EVIDENCE: 1. While performing an audit of the 4th floor medication cart on 05/01/2024, LI observed a round pink pill laying on the bottom of the 3rd drawer, at the back of the left row. 2. The loose pill was also observed by staff 2 and was matched to the VITAMIN B-12 medication card belonging to resident 10. 3. While performing an audit of the 3rd floor medication cart on 05/01/2024, LI observed two round white pills which were stamped with 54|27 laying on the bottom of the 3rd drawer at the back of the middle row. 4. The loose pills were also observed by staff 3 and were matched to the ACETAMINOPHEN 500 MG medication card for resident 11.
Plan of Correction:	1. Perform chart checks daily to determine if there are any cards with loose pills and send back to Pharmacy for repackaging. 2. Educate all RMA?s and Nurses that administer medication to: check the cards when being used to ensure sufficient packaging, and how to send back for repackaging. 3. Track and report all instances to Pharmacy. 4. Check all medication cards when they arrive.