VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Woods Cove Assisted Living
201 W. Criser Road
Front royal, VA 22630
(540) 636-6611

Current Inspector: Jill James (540) 418-2631

Inspection Date: March 16, 2022

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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 63.2 Protection of adults and reporting. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

Discuss with pharmacy adding units to all sliding scales. Recommend twice monthly review of all medication administration records. Review with pharmacy your ordering process for more timely receipt of medication.

Comments:

An unannounced monitoring inspection was completed on site by two licensing inspectors. The current facility census was reported to be 46. Outside inspections were current and postings were as required. Five areas of noncompliance were identified during this monitoring inspection process. They were in the areas of medication administration and management, staff records, staff training, resident admission records and service plans. Details can be found in the violations portion of this report. The systemic violation is under review for requiring an intensive plan of correction. It was noted for physical plant that the facility is continuing with their remodeling process throughout the facility. The facility also has a new administrator who started a week prior to this inspection. Thank you to residents and staff for your cooperation during this inspection process. Should you have additional questions or concerns please call (540) 292-5930 or email this inspector at sharon.deboever@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1140-B
Description:	Based on a review of four staff records, staff A (hired 4/20/21) and D (hired 2/24/20) had did not have 10 hours of training in cognitive impairment in the first four months of employment nor did they have 10 hours of training in cognitive impairment within the first year of employment. Staff B and C, both employed 1/3/22 and 1/4/22 respectively, had less than one hour of documented training related to cognitive impairments. The requirements for mental health and behavior management training were further not met for any of the staff based on interviews.
Plan of Correction:	Forthcoming
Standard #:	22VAC40-73-250-B
Description:	Four staff records were reviewed. The following items were identified as missing from the staff records: Staff B: Hired 1/3/22. No signed orientation, CPR/First Aid to be completed in sixty days or background check to be processed within thirty days was in the file. Staff C: Hired 1/4/22. No signed orientation, CPR/First Aid to be completed in sixty days or updated background check to be processed within thirty days and required for rehires was in the file.
Plan of Correction:	Forthcoming
Standard #:	22VAC40-73-390-A
Description:	Five resident records were reviewed. The following items were identified as missing from the resident records: Resident A: Resident agreement, disclosure and resident rights Resident B: Fall Assessment, Has Agreement but no other paperwork Resident C: Resident agreement, disclosure, resident rights Resident D: Resident agreement, disclosure, resident rights, no physical or TB, no serious cogniitive impairment form or related documentation Resident E: Resident agreement, serious cognitive impairment form and related paperwork Reviews and interviews with administrative staff indicated that the majority of the individuals being funded through Discharge Assistance Planning (DAP) funds do not have facility agreements and many have outdated or unsigned DAP contracts. There is further no documentation regarding resident orientation for any of the residents reviewed or interviewed.
Plan of Correction:	Forthcoming
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records resident C admitted 10/25/21 did not have a comprehensive service plan. The service plan for Resident D does not indicate the special diet required of meals being pureed accompanied by thickened liquids with no directions for thickening. The service plan and UAI also were not reviewed after six months as required for individuals living on a memory care unit. The service plan for Resident O was pulled after medication administration record review due to multiple medication being given for stealing which is not described on the service plan as a sign of anxiety. Only aggression is addressed on the plan.
Plan of Correction:	Forthcoming
Standard #:	22VAC40-73-680-D
Description:	Based on a review of 12 medication administration records, medication was not administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Due to the limited space for typing violations and areas of overlap, specific details have been incorporated into a word document. Areas identified include: 1. Medication not available; 2. Self administration without physician's order; 3. Not following sliding scales for insulin administration; 4. Missed dosages; 5. Medication not administered within parameter given; 6. Medication not given in order prescribed; 7. Medication given outside physician diagnosis; 8. Failure to contact physician for repeated refusals or repeated request as outlined; 9. Orders missing diagnosis or parameters; and 10. Documentation related to medication administration does not meet curriculum guidelines in regards to detail and appropriateness.
Plan of Correction:	Forthcoming