An Agency of the Commonwealth of Virginia
Click Here for Additional Resources
Search for an Assisted Living Facility
|Return to Search Results | New Search |

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

Current Inspector: Janice Knight (540) 430-9258

Inspection Date: May 23, 2022 and May 24, 2022

Complaint Related: No

Areas Reviewed:

Technical Assistance:
Recommended sending all changed/updated forms and policies (such as the fire drill form, disclosure, staffing plan, etc.) to licensing inspector for review prior to implementation.

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: 8:45 am to 5:30 pm on 5/23/2022 and 8:20 am to 5:30 pm on 5/24/2022.
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: 35
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 7
Number of staff records reviewed: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 4

Observations by licensing inspector: Completed medication administration observations for five residents, observed activities, meals and special diets.

An exit meeting will be conducted to review the inspection findings.

The evidence gathered during the inspection determined non-compliance with applicable standards, 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 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:

Should you have any questions, please contact Janice Knight, Licensing Inspector at (540) 430-9258 or by email at

Standard #: 22VAC40-73-70-A
Description: Based upon documentation and an interview, the facility failed to ensure a major incident was reported to the licensing office within 24 hours.

1. A wound clinic note completed 3/31/2022 for resident 6 stated, "Wound progressing appropriately. Healing with a 16.7% decrease in overall surface area from last visit. Appropriate for ALF from wound care perspective."

2. Resident 6 (admitted 4/2/2022), had a hospice nursing note stating, "Stage III fu to coccyx pink wound bed no drainage."

3. On 5/23/2022, the licensing inspector (L)I interviewed the administrator who stated she had not reported this information to the licensing office.

Plan of Correction: Administrator was on medical leave 4/1/22 through 4/5/22. Licensing inspector has been notified of resident 6's wound effective May 24, 2022. No other wounds are being treated in the facility at this time to report. Nursing notes will be reviewed prior to admission for all residents by administrator or supervisor in charge and LI will be notified by administrator or supervisor in charge within 24 hours of resident's admission, of any stage 2 or greater wounds, effective May 24, 2022.

Standard #: 22VAC40-73-450-C
Description: Based upon documentation and an interview, the facility failed to ensure all required needs and services provided were included on one of seven individualized service plans (ISPs) reviewed.

1. The ISP (completed 4/2/2022) for resident 6 (admitted 4/2/2022) did not include the specific services to be provided by facility staff regarding monitoring the stage 3 and healing dermal ulcer.

2. The ISP for resident 6 indicated resident was a full code; however, a do not resuscitate order was completed and signed on 4/6/2022 and a copy was in the resident?s file.

3. On 5/23/2022, the LI interviewed the administrator who reviewed the ISPs and stated the information was not listed on the ISPs.

Plan of Correction: The ISP for resident 6 has been corrected as of May 24, 2022, to include services provided by facility staff regarding monitoring of Stage 3 and healing dermal ulcer.
The ISP for resident 6 has been corrected to show resident code status is DNR as of May 24, 2022.
The administrator will review all changes made by supervisor on ISPs as changes are made to ensure compliance. Administrator and supervisor reviewed resident 6's ISP for accuracy on May 24, 2022. Administrator and supervisor will review all ISPs for compliance by June 3, 2022.

Standard #: 22VAC40-73-680-D
Description: Based upon documentation and interviews, the facility failed to ensure two medications for one of five residents reviewed was administered according to the physician's order and the Virginia Board of Nursing's approved medication aide curriculum.

1. Resident 1 had an order signed 4/29/2022 for, "0.125mg Digoxin po on Monday, Wednesday, Fridays only."

2. The May electronic medication administration record (EMAR) listed, "Digoxin 0.125mg take one tablet by mouth on Monday Wednesday and Friday for Afib."

3. The May EMAR was signed for 8:00 am 5/6/2022 through 5/23/2022 and the pulse was documented daily.

4. Medication Aide Curriculum states on page 44, Section 2.6, "The rules for medication administration are universal. We call these rules the "Five Rights" of Medication Administration. These rules apply to every medicine, every client and ever HCP at all times.

A. The Five Rights
1. Right Client
2. Right Drug
3. Right Dose
4. Right Route
5. Right Time"

5. Resident 1 had an order signed 5/19/2022 for polyethylene glycol, mix contents of one capful in liquid and drink by mouth as needed for constipation at 8:00 am.

6. On 5/24/2022, the licensing inspector (LI) interviewed the administrator and she stated the error was found on 5/23/2022 and the medication aides were interviewed and stated the medication was being given every day.

Plan of Correction: The Digoxin order was reviewed for accuracy. The doctor was contacted and ordered resident 1 to continue taking medication as ordered on Mondays, Wednesdays and Fridays. The medication is being administered as ordered effective May 24, 2022. All medication aides have been counseled on reading orders on EMAR prior to medication administration. A training on best practices for administration of medication is being scheduled for all medication aides by nurse from contract pharmacy. Administrator and supervisor will conduct audits on all new orders as they are received. Rights to merge orders in EMAR have been limited to administrator or supervisor only, effective May 24, 2022, to ensure administrator and supervisor are reviewing all new orders daily.

Resident 1's order for Polyethylene Glycol was reviewed. Medication aides were interviewed and advised they ask resident 1 each morning at 8:00 am if medication is needed per order. If not needed, medication aide documents on EMAR not given per resident refusal/loose stools. Order has been sent to doctor for clarification as to if medication should be scheduled or prn. Upon receipt of doctor's response, administrator or supervisor will notify pharmacy of order change for EMAR to be updated. All new orders will be reviewed by administrator and supervisor as received for scheduled versus prn status when merging on EMAR, effective May 24, 2022.

A compliance history is in no way a rating for a facility++.

The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.

Google Translate Logo