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. 6, 2023 and Feb. 7, 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 ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 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:

1. Recommended including specific amounts of water to be delivered on the emergency water agreement. 2. Hot water temperature registered 119.7 degrees Fahrenheit (F) ? ensure this is monitored to avoid going above 120 degrees F. 3. Carefully review all paperwork prior to filing to ensure completion and accuracy. Rather than leaving not applicable information blank, write not applicable in the space (such as on physicals, do not resuscitate orders, social data forms, etc.). 4. Submit a copy of the fire and health inspections to the licensing inspector once received.

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: 2/6/2023 from approximately 6:45 am to 5:40 pm and 2/7/2023 from approximately 7:00 am to 3:45 pm 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: 28 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 + selected sections of 2 additional records + 2 contract staff Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Postings, meals, activities, medication administration, first aid kit, staffing, communication log, food consumption log, medication cart, emergency food and water, etc. Additional Comments/Discussion: A preliminary review of all violations was completed with the administrator at the end of each day of the inspection. Opportunity was given each day to ask questions and to provide any additional information related to the violations. An exit meeting will be conducted to review the inspection findings. 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-410-A
Description:	Based upon documentation and an interview, the facility failed to ensure two of six residents signed the orientation form. Evidence: 1. Resident 1 (admitted 4/3/2022) and resident 6 (admitted 4/7/2022) did not sign the resident orientation form upon admission. Instead, the residents? family members signed the forms. 2. On 2/7/2023, the licensing inspector (LI) interviewed the administrator who stated both residents were capable of signing the form and the family members were present with the residents when the orientation occurred; however, the family members signed the forms instead of the residents.
Plan of Correction:	One of the two residents that did not sign their own Resident Orientation Checklist has been discharged from the facility. The resident still residing at the facility has now signed her own Resident Orientation Checklist as the administrator explained to her we need her signature versus her power-of attorney?s (POA's) signature on the form. An audit of every resident's chart has been completed by administrator and supervisors to ensure all other current residents have signed their own Resident Orientation Checklist. Supervisors have been made aware the resident must sign the Orientation Checklist versus the resident's POA. The administrator will check every new Resident's Orientation Checklist on date of admission to ensure they are the person that signs this form. The audit of all charts was completed on February 14, 2023.
Standard #:	22VAC40-73-450-F
Description:	Based upon documentation and an interview, the facility failed to ensure three of the six individualized service plans (ISPs) reviewed were updated when the residents? needs changed. Evidence: 1. Resident 1 had a physical therapy (PT) order and notes on file indicating resident received services from 8/23/2022 through 10/20/2022. 2. The ISP (signed 5/3/2022) was not updated to include PT services and the discontinuation of those services. 3. Resident 3 had a physician?s order signed 2/17/2021 for a no added salt (NAS) diet. The diet was changed to a regular diet, according to a physician?s order signed 5/14/2021. 4. The ISP (signed as completed 5/17/2022) for resident 3 still listed a NAS diet. 5. Resident 5 had a physician?s order signed 9/15/2022 for a NAS diet. 6. The ISP (signed as completed on 8/21/2022) still listed resident 5?s diet as regular. 7. Resident 5 had a fall risk rating completed on 7/20/2022 and 2/5/2023 and both scored resident as a high risk for falls. 8. The ISP (signed as completed on 8/21/2022) did not include the resident?s risk for falls and fall precautions.
Plan of Correction:	Resident 1's ISP has been updated to reflect her home health services received from 8/23/2022-10/20/2022. Resident 3's ISP has been updated to reflect regular diet effective 5/14/2021. Resident 5's ISP has been updated to reflect NAS diet effective 9/15/2022. Resident 5's ISP has been updated to reflect he was a fall risk effective 7/20/2022. The administrator and supervisors are conducting an audit of all resident charts to ensure all changes to diet, fall risk, home health, etc. are reflected on their ISPs. The administrator developed a master spreadsheet to track all changes made daily regarding all residents' care. This spreadsheet will help the administrator and supervisors ensure all changes to residents' care are updated on master logs, physicians? order sheets (POSs), Uniform Assessment Instruments (UAIs), ISPs, etc. as there is a section for each supervisor to sign off on and acknowledge they have updated the residents' records appropriately. The administrator will review and oversee the master spreadsheet of changes to ensure all changes are recorded where appropriate in the residents' charts. All chart audits will be completed by February 17, 2023.