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: June 7, 2024

Complaint Related: No

Areas Reviewed:

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 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

Discussed keeping the dietary manual kept in a conspicuous place to make readily available for dietary staff to review as needed.

Comments:

Type of inspection: ?Monitoring? Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/7/24 10:00am ? 4:15 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: 41 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch meal pass, memory care unit dining area, food storage, building grounds. Additional Comments/Discussion: n/a 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov Violation Notice Issued: ?Yes?

Violations:

Standard #:	22VAC40-73-290-B
Description:	Based on observation and staff interview, the facility failed to ensure it posted the name of the current on-site person in charge in the facility that is conspicuous to the residents and the public. Evidence: 1. During the building tour on 6/7/2024 licensing inspectors did not observe the person in charge conspicuously posted for the public. 2. Staff 7 acknowledged that the person in charge was not posted.
Plan of Correction:	The facility has begun to highlight all in-charge persons on its available and posted schedules. Additional signage is currently being looked into and will be purchased when it is determined that it meets the appropriate criteria. Expected to be completed by August 31 , 2024.
Standard #:	22VAC40-73-440-H
Description:	Based on record review and staff interview, it was determined that the facility did not ensure that an updated uniform assessment instrument (UAI) was completed at least annually to determine whether a resident's needs can continue to be met by the facility, and whether continued placement in the facility is in the best interest of the resident. Evidence: 1. Resident 1 (date of admission 12/5/2018) UAI was last completed on 4/28/23. 2. Resident 4 (date of admission 9/13/2021) UAI was last completed on 4/27/23. 3. Staff 7 acknowledged the UAIs were not completed annually.
Plan of Correction:	The UAl's for both Resident 1 and Resident 4 were completed while inspectors were onsite. The facility will monitor resident UAI completion dates more closely going forward. Correction completed July 18, 2024. .. Creating an excel document that highlights upcoming expiration dates is a possibility and is being considered.
Standard #:	22VAC40-73-610-B
Description:	Based on observation and staff interview, the facility failed to ensure the menu with meals and snacks for the current week shall be posted. Evidence: 1. During observation of lunch on 6/7/2024 the lunch meal was posted on a white board and mislabeled as breakfast. 2. Staff 7 acknowledged a weekly menu with a list of available snacks was not posted. 3. Photo evidence taken.
Plan of Correction:	The weekly menu is now posted. Kitchen staff has been informed that a weekly menu must be posted in a conspicuous place for residents and staff. Correction completed.
Standard #:	22VAC40-73-620-A
Description:	Based on record review and staff interview, the facility failed to ensure dietary oversight was conducted every six months for special diets by a dietitian or nutritionist. Evidence: 1. Dietary oversight was completed on 3/13/2023 and 5/21/2024. 2. Staff 7 acknowledged that the dietary oversight was not completed every six months.
Plan of Correction:	The previous dietician had moved to another state, which resulted in noncompliance. A new dietician was hired, and a dietary oversight was completed in May of 2024. The dietician will remain contracted and perform another dietary oversight in November of 2024.
Standard #:	22VAC40-73-930-B
Description:	Based on observation and staff interview, the facility failed to ensure a building licensed to care for 20 or more residents under one roof, there shall be a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal. Evidence: 1. During a tour of the facility on 6/7/2024 the licensing inspectors observed signaling devices in resident rooms were not operational. 2. Staff 7confirmed the signaling system was not operational and resident rooms did not have a signaling device. Staff 7 stated they have been getting quotes and working on updating the call system.
Plan of Correction:	A call/signaling system will be installed once the appropriate permits are issued. Residents will use handbells until a call/signaling system is installed. There is no timeline currently for its installation. The facility's architect has been in communication with the Building and Zoning Department regarding any changes that must be made to the facility's architectural plans for the permits to be approved. The facility will inform the state licensee once the installation is completed.
Standard #:	22VAC40-73-940-A
Description:	Based on record review and staff interview, the facility failed to ensure the annual fire inspection was completed. Evidence: 1. Record of the last fire inspection was completed on 6/16/2022. 2. Staff 7 acknowledged the fire inspection was not current.
Plan of Correction:	An annual fire inspection will be performed before year's end. The facility had believed that the fire inspection was up to Warren County Fire Dept. to schedule all inspections. The facility will have better communication with the Warren County Fire Dept. in establishing a time for the yearly inspection.
Standard #:	22VAC40-73-980-H
Description:	Based on observation and staff interview, the facility failed to ensure the availability of a 96-hour supply of emergency drinking water. At least 48 hours of the supply must be on site at any given time. Evidence: 1. During a tour of the facility on 6/7/2024 licensing inspectors observed emergency water was not present. 2. Staff 7 stated there currently is not emergency water.
Plan of Correction:	Stackable water storage units have been ordered, but not yet delivered. Once they arrive, the appropriate amount of water will be ordered and stored. Expected to be completed by August 31 , 2024