VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Legacy at North Augusta, Inc.
1410 A N. Augusta Street
Staunton, VA 24401
(540) 885-5454

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Oct. 19, 2022 and Oct. 20, 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 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 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:

Ensure language used is appropriate to services provided ? first aid versus wound care. If treatment provided is for wound care, then only nurses may provide the care. If any area is open and beyond the superficial layer, then it is considered wound care. Only superficial skin care, such as a skin tear that requires first aid, may be provided by a registered medication aide. Ensure physicians? orders include the correct wording to ensure on-going compliance.

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: 10/19/2022 from approximately 7:10 am to 6:45 pm and 10/20/2022 from approximately 7:30 am to 7:15 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: 89 (74 assisted living, 15 secured unit) The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 + selected section of one additional record Number of staff records reviewed: 4 + 2 agency staff + selected sections of 3 additional staff + I volunteer Number of interviews conducted with residents: 6 Number of interviews conducted with staff: 6 Observations by licensing inspector: Completed medication administration observations for three residents and reviewed the October 2022 medication administration records, signed physicians? orders and medications for those residents. Also observed activities, meals, required postings and staffing. Additional Comments/Discussion: Checked the stat box, first aid kit, reviewed the health care oversights and special diets and three private sitter records. 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 #:	22VAC40-73-1140-B
Description:	Based upon documentation and an interview, the facility failed to ensure four of six staff completed at least 10 hours of dementia training within the first four months of hire. Evidence: 1. Staff 2 (hired 9/20/2021) completed 6 hours of dementia training from 9/20/2021 to 1/20/2022. 2. Staff 4 (hired 11/1/2022) completed 4 hours of dementia training from 11/1/2022 to 3/1/2022. 3. Staff 8 (hired 6/1/2022) completed 5 hours of dementia training from 6/1/2022 to 10/1/2022. 4. Staff 9 completed 1 hour of dementia training from 5/1/2022 to 9/1/2022. 5. On 10/20/2022, the Li interviewed ED who stated these were the only training hours completed for these staff.
Plan of Correction:	Steps to correct non-compliance: staff completed required dementia training. The department director/education director will audit dementia training completion monthly for new hires. New hires will be notified immediately to complete training for compliance
Standard #:	22VAC40-73-260-C
Description:	Based upon observations, documentation and an interview, the facility failed to ensure the posting with staff who were certified in first aid (FA) and cardiopulmonary resuscitation (CPR) remained current. Evidence: 1. On 10/19/2022, the licensing inspector (LI) observed the posted list of staff with current FA and CPR in the second floor care base on the bulletin board. The list was dated May 2022. 2. The list did not include staff that were hired since July 2022. 3. On 10/20/2022, the executive director (ED) reviewed the list and stated it did not include staff hired since July 2022.
Plan of Correction:	Notified scheduler to update CPR/First Aid posting. Updated list posted. The scheduler will update list upon new hires and renewal of certification. The Care Coach will audit monthly for compliance
Standard #:	22VAC40-73-560-E
Description:	Based upon observations and interviews, the facility failed to ensure resident records were kept in a locked area. Evidence: 1. During the facility tour on 10/19/2022, the LI observed the care base on the first floor unlocked and unattended. Resident records were stored in an unlocked cabinet in the care base. 2. On 10/19/2022, the LI interviewed staff 6 who stated she was told as long as the door was shut it did not need to be locked.
Plan of Correction:	Locked and secured the door immediately. Staff retrained on the necessity of keeping the door closed and locked when unattended. All new staff will be trained upon hire. The Care Coach/ED or designee will perform daily rounds to ensure compliance
Standard #:	22VAC40-73-860-I
Description:	Based upon observations and interviews, the facility failed to ensure all cleaning supplies were kept in a locked storage area. Evidence: 1. During the facility tour on 10/19/2022, the LI observed two large containers of bleach in the first floor hallway outside of the maintenance storage closet. The containers were left in an unlocked area and were unattended. Also, the cleaning supply closet in the kitchen was observed by LI with the door open, key in the lock and unattended. 2. LI showed staff 7 the open cleaning closet and she stated it should be locked. 3. The LI also showed the ED the containers of bleach and she stated the staff know better than to leave cleaning supplies unlocked.
Plan of Correction:	The two containers were immediately moved to a lock area. Secured the cleaning supply closet immediately and removed key from lock. Staff retrained on the necessity of keeping all cleaning supplies locked at all times. All new staff will be trained immediately upon hire. The Facilities Manager or designee will ensure compliance through daily rounds.