VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Waynesboro Manor
809 Hopeman Parkway
Waynesboro, VA 22980
(540) 942-2250

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: Feb. 10, 2020 and Feb. 11, 2020

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 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.

Technical Assistance:

Answered questions and discussed the following: 1) Answered questions about tuberculin skin tests/assessments and confirmed they are no longer accepted from another facility unless they meet the time frame requirement of being no older than 30 days (250.D). 2) Ensure when information is sent out from this agency that the material is implemented within the required time frame (disclosure, etc). 3) Discussed what steps to take when a resident refuses to give mental health progress reports to the facility. 4) Continue to monitor hot water temperature as it registered 104.5 degrees Fahrenheit in a resident's room. 5) Discussed difficulty of keeping inside temperature stable due to the constant extreme changes in outside temperatures, suggested to just continue to monitor and adjust accordingly as are doing. 6) Recommended adding a sentence at the bottom of the activity calendar indicating the minimum length of each activity (due to limited space on the calendar). 7) Fire inspection is due in March; however, license can not be issued until inspection is completed and a copy is sent to the licensing inspector. 8) Ensure when posting the Violation Notice that it is not covered with the Summary Sheet. (Note: You are not required to post the Summary; however, both the Summary and Violation Notice were posted).

Comments:

An unannounced renewal inspection was conducted on 2/10/20 from 7:50 am to 4:45 pm and on 2/11/20 from 7:15 am to 5:15 pm. A tour was immediately conducted of the interior and exterior of the facility. The facility was clean and free from any foul odors. Upon arrival there were three direct care staff and one registered medication aide (RMA) on duty and 30 residents in care. The posted menu and activities calendar were current and accurately reflected this inspector's observations. The special diets observed were served according to the physicians' orders. Medication administration observations were completed for four residents with one RMA. The January and February 2020 medication administration records (MARs), physicians' orders and medications were reviewed for all four residents. Individual interviews were conducted with residents and staff; however, there were no family members available to interview during the inspection. Seven resident, one discharge, six staff and two contract staff records were reviewed. Selected sections of eight additional resident records were also reviewed. The areas of noncompliance included the disclosure, infection control policy, first aid training, sex offender registry information reviews, individualized service plans, medication management plan, medication administration, MAR documentation and as needed medication availability and labeling. Staff obtained all information requested and answered all questions. Thank you for your assistance and cooperation during this inspection. NOTE: The fire inspector's report must be submitted to the licensing inspector prior to a new license being issued.

Violations:

Standard #:	22VAC40-73-100-A
Description:	Based upon an interview, the facility failed to ensure the infection control policy and procedures were reviewed annually for any necessary updates. Evidence: On 2/11/20, the LI interviewed the administrator regarding the infection control policy and she stated the policy had not been reviewed annually for updates by herself and a health care professional.
Plan of Correction:	Administrator has reviewed the infection control policy and procedures for updates. Administrator will email infection control policy and procedures to RN for review. Any suggested updates by RN will be made. Administrator will use the March health care oversight date as the annual date to review infection control policy and procedures by administrator and health care professional.
Standard #:	22VAC40-73-50-A
Description:	Based upon documentation and an interview, the facility failed to ensure the disclosure was on the most current model form and included all required information for two of the seven resident records reviewed. Evidence: 1) The disclosure forms signed by resident F (admitted 1/25/20) and O (admitted 12/30/19) did not include the required generator information and was not on the most current model form. 2) On 2/11/20, the LI interviewed the administrator who stated the newest model form had not yet been implemented
Plan of Correction:	Residents F and O signed the newest model disclosure form on 2/11/20. All new resident admission packets have been updated with the new disclosure form. Administrator will ensure all new and current residents receive the newest disclosure form.
Standard #:	22VAC40-73-260-A
Description:	Based upon record reviews and an interview, the facility failed to ensure one of six staff records reviewed had documentation of first aid training completion. Evidence: 1) Staff D (hired 9/29/19) had no documentation on file of first aid training certification. 2) On 2/11/20, the LI interviewed the administrator who stated staff D had not completed first aid training.
Plan of Correction:	Staff D will complete first aid training by 3/15/20. Administrator will review all new hire records within the first week of hire to ensure first aid training has been completed or scheduled. Administrator will ensure all staff hired complete first aid training within 60 days of hire. The administrator will conduct a monthly review of all staff records to ensure first aid training is completed within 60 days of hire and that all first aid training is kept current at all times.
Standard #:	22VAC40-73-350-C
Description:	Based upon record reviews and an interview, the facility failed to ensure five of the ten resident records reviewed included documentation of a review of the sex offender registry information. Evidence: 1) Residents A, D, J, L and M did not have documentation of an annual review of the sex offender registry information. 2) On 2/11/20, the LI interviewed the administrator who stated an annual review of the sex offender registry information was not conducted last year.
Plan of Correction:	Residents A, D, J, L and M, as well as all other residents, reviewed the sex offender registry information on 2/11/20. Administrator will ensure all new residents review and sign sex offender registry policy. Administrator and supervisor will ensure every February all residents review and sign the sex offender registry policy
Standard #:	22VAC40-73-450-F
Description:	Based upon documentation and interviews, the facility failed to ensure four of the seven individualized service plans (ISPs) reviewed were updated to include all needs and services provided. Evidence: 1) the ISP (completed 7/30/19) for resident A did not include fall risk information as resident was assessed as a high risk for falls; ISP (completed 4/16/19) for resident B did not include physical assistance with toileting; ISP (completed 11/5/19) for resident E did not include the do not resuscitate order which was dated as 11/10/19; ISP (completed 1/25/20) for resident F did not include physical therapy and high risk for falls. 2) On 2/11/20, the LI interviewed the administrator and supervisor and both stated these needs were not listed on the ISPs.
Plan of Correction:	ISPs for residents A, B, E and F have been updated. Fall risk information will be added to all ISPs (if residents are a high risk for falls) as the assessments are completed at admission, annually and after each fall, if resident is a high risk for falls. Administrator and supervisor will review all uniform assessment instruments (UAIs) and ISPs annually and as residents' care needs change, to ensure ISPs are current and have accurate documentation.
Standard #:	22VAC40-73-640-A
Description:	Based upon observations, documentation and interviews, the facility failed to develop and implement a medication management plan that would ensure expired medications were disposed of. Evidence: 1) On 2/10/20, the LI conducted an audit of both medication carts and observed the following: Cart B had Acetaminophen (expired 4/19), Anti-diarrheal (expired 5/19), EQ Tussin (expired 12/12/19), and Tussin (expired 1/20). Cart C had Arthritis Pain Relief (expired 1/19) and Robitussin (expired 9/19). 2) On 2/10/20, the LI interviewed the registered medication aide (RMA)/supervisor and administrator and all confirmed the medications had expired. The administrator also stated cart audits were not being completed.
Plan of Correction:	All expired medications have been disposed of per medication management plan policy. If medication was on the MAR, it was replaced. If medication was no longer on the MAR, it was disposed of. Cart audits will be completed weekly by RMA assigned by administrator and monthly by the administrator. Administrator will create a checklist for audits to include checking all medication expiration dates.
Standard #:	22VAC40-73-680-D
Description:	Based upon documentation and interviews, the facility failed to ensure one medication for one of four residents was administered according to the physician's order. Evidence: 1) Resident D had a signed physician's order to administer Novolog Flexpen insulin as follows: two units if 150 or below; four units if 151-200; six units if 201-250; seven units if 251-300; eight units if 301-350; ten units if 351-400 and call doctor. 2) According to the medication administration record (MAR), the blood glucose level (BGL) on 1/1/20 at 4:00 pm was 257 and only six units were administered; on 1/25/20 at 11:00 am the BGL was 144 and on 2/2/20 at 11:00 the BGL was 142 and no insulin was administered either time; on 1/27/20 at 4:00 pm the BGL was 167 and five units were administered. 3) On 2/10/20, the licensing inspector (LI) interviewed the administrator and supervisor and both reviewed the MARs and stated the insulin was not administered properly on the dates and times listed.
Plan of Correction:	Resident D's physician's order and the January and February MARs were reviewed. Staff member that incorrectly administered sliding scale units was counseled. Administrative supervisor will conduct random medication administration observations in addition to quarterly observations during administration of sliding scale for monitoring compliance. Administrator will review other residents' MARs that have sliding scale orders to ensure units have been administered per physicians' orders. Administrator will contact registered nurse (RN) to schedule in-service on diabetes for all registered medication aides (RMAs). The administrator and administrative supervisor will review MARs monthly to ensure compliance.
Standard #:	22VAC40-73-680-I
Description:	Based upon documentation and interviews, the facility failed to ensure three of the four MARs reviewed included all of the required information. Evidence: 1) The January and February MARs for resident A did not include a diagnosis for Amiodarone, Bumetanide, Docusate, Folic Acid, Metolazone, Potassium Dur, Warfarin and Albuterol. The MARs also listed multiple orders for Lorazepam and Oxycodone; however, the specific symptoms for administering were not listed. 2) The February MAR for resident D did not include a diagnosis for Milk of Magnesia; on 1/27/20 at 11:00 am the BGL was not documented and on 2/3/20 at 4:00 pm the amount of Novolog administered was not documented. The MARs also listed multiple orders for Lorazepam and Morphine and the specific symptoms for administering were not listed. 3) The January and February MARs for resident N did not include a diagnosis for Albuterol, Amlodipine, Hydralazine and Ursodiol. 4) On 2/10/20, the LI interviewed the administrator and supervisor and both stated none of the above information was included on the MARs
Plan of Correction:	Administrator printed MARs for residents A, D and N. Administrator and supervisor identified missing information on MARs and will send physicians' order sheets (POSs) to the residents' physicians and request the missing information be updated and signed. Once received, POSs will be sent to pharmacy for entry onto MARs. Administrator and supervisor will print all residents' MARs, identify any missing information and send POSs to their physicians' for MAR compliance. Administrator and supervisor will review MARs monthly to ensure diagnosis, symptoms for administering and blood glucose levels are correctly documented.
Standard #:	22VAC40-73-680-M
Description:	Based upon observations, documentation and interviews, the facility failed to ensure all as needed (PRN) medications were available and properly labeled. Evidence: 1) On 2/10/20, the LI conducted an audit of both medication carts and observed the following: In cart B bottles of Vitamin D-3 and Vitamin E were not labeled with a resident's name; in cart C two bottles of Tylenol, three bottles of Arthritis Pain Relief, one bottle of Senna - S, aspirin, cranberry supplement and Vitamin D-2 were not labeled with a resident's name. 2) The following PRN medications were not available: Hydroxyzine for resident A; Greer's Goo and Quetiapine for resident D; Polyethylene Glycol for resident N. 3) On 2/10/20, the LI interviewed the RMA, supervisor and administrator and all stated the medications listed above were either not available or not labeled with a resident's name, as indicated above.
Plan of Correction:	All bottles in both carts have been labeled with residents' first and last names. The PRNs not available were reordered or discontinued by residents' physicians. Cart audits will be completed weekly by RMA assigned by administrator and monthly by administrator. Administrator will create a checklist for cart audits to include checking all bottles for first and last names and expiration dates, as well as the presence of all PRNs.