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

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: 5/30/2024 8:45am ? 6:30pm; 5/31/2024 8:30am - 6:25 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: 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: 4 Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing Inspector observed residents participating in activity programs and eating lunch and dinner. This LI also observed staff assisting residents, activities, and medication pass. 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 #:	22VAC40-73-200-D
Description:	Based on record review and staff interview the facility failed to ensure qualifications for 1 of 4 staff records reviewed included certification or other documentation. EVIDENCE: 1.The record for Staff 3 (date of hire 12/21/2023) and Staff 4 (date of hire 5/1/2017) did not contain documentation of completion of direct care staff training. 2.Staff 5 acknowledged the qualifications were not at the facility.
Plan of Correction:	The Executive Director or designee will ensure documentation of staff qualifications is on file in staff records. The ED or designee will audit staff records to ensure compliance.
Standard #:	22VAC40-73-350-C
Description:	Based on staff interview, the facility failed to ensure an annual review of information on the sex offender registry, including how to obtain such information and to ensure that written acknowledgment of having been so informed was provided to the resident or his legal representative and shall be maintained in the resident's record. EVIDENCE: 1 LI requested documentation of resident acknowledgement of receipt. 2. Staff 5 acknowledged that annual review and documentation of informing residents of the sex offender registry was not completed and on file.
Plan of Correction:	All resident or legal representative will be notified and will complete Sex Offender acknowledgment form. The administrator registered with the State Police to be listed for notification from the Department of State Police sex offender registry notification.
Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to ensure required resident personal and social information was obtained prior to or at the time of admission. EVIDENCE: 1.The record for Resident 3 (admitted 2/2/2024) and Resident 4 (admitted 2/2/2024) did not contain lifetime vocation and hobbies. 2.Staff 5 acknowledged that the personal and social information was not complete for these two residents.
Plan of Correction:	Current resident social data forms will be reviewed and updated. Social data form will be completed prior to admission to the community. Administrator or designee will review for completion prior to admission.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation, the facility failed to ensure that the medication storage area was locked. EVIDENCE: 1. During the physical plant walk through on 5/31/2024 a medication cart was not locked and the door leading into the medication room was also not locked. 2. Photo evidence was taken and presented to Staff 5.
Plan of Correction:	All staff were retrained to ensure medication storage areas are locked. All RMA will be re-educated on the medication management policy which includes procedures for proper storage.
Standard #:	22VAC40-73-930-D
Description:	Based on staff interview, the facility failed to ensure that documentation of staff rounds was completed that included the name of the resident, date and time of rounds, and the staff member who made the rounds for residents who were unable to use the signaling device. EVIDENCE: 1. The LI requested Staff 5 provide a resident round log sheet. 2. Staff 5 stated the previous administrator discontinued this process months before she left. Staff 5 confirmed the resident round log were not utilized.
Plan of Correction:	All staff will complete rounding on all residents and document in rounding log. Rounding log will be reviewed at the end of each shift. Administrator/RCC will review log daily.
Standard #:	22VAC40-73-960-C
Description:	Based on observation and staff interview, the facility failed to ensure the telephone numbers of the fire department, rescue squad or ambulance, police, and Poison Control Center were posted by each telephone shown on the fire and emergency evacuation plan. Evidence: 1. On May 30, 2024, during a tour of the facility, the two licensing staff observed the emergency numbers were not posted near telephone shown on the facility evacuation plan. 2. Staff 5 acknowledged that emergency numbers were not posted. 3. Photo evidence taken.
Plan of Correction:	Corrected while inspectors were on site. Posted telephone numbers for fire department, rescue squad, police, and poison control center by each telephone.
Standard #:	22VAC40-73-990-A
Description:	Based on staff interview the facility failed to ensure there were written policies and procedures for resident emergencies. EVIDENCE: 1. LI requested written policies and procedures for resident emergencies, and they were not provided. 2. Staff 5 acknowledged that there were no written procedures for resident emergencies.
Plan of Correction:	The Executive Director or designee will ensure the Resident Emergency Review shall be reviewed by all staff at the community every 6 months and during general orientation.
Standard #:	22VAC40-90-40-B
Description:	Based record review, the facility failed to ensure the criminal history record report were obtained on or prior to the 30th day of employment. EVIDENCE: 1.The record for Staff 2 (date of hire 12/13/2023) did not contain a criminal history record (CHRRs). 2.The record for Staff 3 (date of hire 12/21/2023) the CHRR was dated 2/12/2024. 3. The record for Staff 6 (date of hire 10/9/2023) the CHRR was dated 11/29/2023. 3.Staff 5 acknowledged the CHRR for Staff 2 was not in the staff record and Staff 3 verified the dates on the CHRR were correct.
Plan of Correction:	: All staff records will be audited for criminal background compliance.