VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Whispering Pines Assisted Living Facility
200 Leaksville Road
Luray, VA 22835
(540) 743-2273

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: May 30, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 63.2- (16) PROTECTION OF ADULTS AND REPORTING

Technical Assistance:

N/A

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: 5/30/24 8:45am-3:10pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on May 18, 2024 regarding allegations in the area of: Resident Care and related services. Number of residents present at the facility at the beginning of the inspection: 26 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Licensing Inspector observed residents participating in activity programs and eating lunch and dinner. The LI also observed the operation of the front door locking system to avoid residents wandering out of the building. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-70-C
Description:	Based on communication with the facility, the facility failed to provide a written report of a major incident that threatened the health, safety, or welfare of the resident to the regional licensing office within seven days from the date of the incident. EVIDENCE: 1. Staff 5 emailed an initial self-report of the resident wandering out of the building on 5/18/2024. 2. On 5/26/2024 the LI requested the 7 day follow up regarding this incident from Staff 5. 3. The licensing office did not receive the written report until May 30, 2024.
Plan of Correction:	All major incidents that threatened the health, safety, or welfare of the resident will be reported within seven days of the incident.
Standard #:	22VAC40-73-290-A
Description:	Based on record review and staff interview, the facility failed to ensure the staff schedule included the job classification of all staff working each shift and indicated who was in charge at any given time. EVIDENCE: 1. Staff schedules were requested and reviewed from 4/19/2024 through 5/30/2024. Schedule did not include the job classification and who was in charge at any given time. 2. Staff 6 acknowledged that the job classification and who was in charge at any given time was not on the schedule.
Plan of Correction:	Staff schedule was corrected to show name, job classification, and shift. Corrected while inspector was on site.
Standard #:	22VAC40-73-460-D
Description:	Based on record review and staff interviews, the facility failed to ensure that supervision of resident care was provided, including prevention from wandering from the premises. EVIDENCE: 1. The facility had a mixed population and did not have a secure unit. 2. The facility policy was reviewed and section Pre-Admission Wandering and Elopement Risk Screening part 1 states an ?The approved Pre-Admission Wandering Risk and Elopement Screening forms will be used to complete a screening on all potential admissions prior to the admission date.? The Elopement Screening will be completed quarterly, when there is a change in cognition, or post elopement episode. 3. A Pre-Admission Elopement Screening was completed on 7/25/2023, (Resident 1 was admitted 7/27/2023). Resident 1 scored 10 on the elopement screening with a score of 10 or greater qualifying for interventions including being placed on the elopement risk list and a wander alert system. A handwritten note included on Resident 1 screening form stated, ?resident has no history of elopement will monitor if additional procedures need to be followed.? 4. On 5/30/24 Staff 5 stated Resident 1 did not have a wander guard at the time of this incident. 5. Review of Resident 1 record did not contain evidence of quarterly monitoring, elopement screening documentation, and post elopement episode documentation per facility Wandering and Elopement Policy and Procedure. 6. Resident 1 assessment completed on 8/28/2023 by Staff 6 stated Resident 1 ?has episodes of confusion with hallucinations and needs redirection.? Also, ?she has impaired judgement and memory.? 7. Individual Service Plan dated 9/14/2023, identified Resident 1 being disoriented to time and place and for staff to reorientate resident to highest ability. 8. On 5/18/24 at 1:15pm, Resident 1, who has a diagnosis of dementia, exited the building and was found standing on the edge of the facility parking lot near the primary two-lane road. Resident 1 was brought back to the facility by a concerned citizen at 1:25pm. 9. Staff 2 stated they were in the dining area when an older gentleman approached them and said they were going down the road and saw Resident 1 in the parking lot by the bushes and the garage, realized Resident 1 resided at the facility and brought the resident back to the front door. 11. Photo evidence of exterior of facility.
Plan of Correction:	Residents with wander guard will be monitored per facility?s policy. Staff will review wander guard policy and complete annual elopement training.