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: March 31, 2023

Complaint Related: Yes

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Technical Assistance:

None.

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/31/2023 from approximately 9:37 am to 5:20 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 3/28/2023 regarding allegations in the areas of: Administrative and Administrative Services, Resident Care and Related Services and Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 1 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 8 Observations by licensing inspector: On the secured unit: Resident rooms and common areas, medication administration and documentation and staff and resident record reviews. Additional Comments/Discussion: Staff schedules and progress notes were also reviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-I
Complaint related:	Yes
Description:	Based upon documentation, the facility failed to ensure all required information was included on three of three medication administration records (MARs) reviewed. Evidence: 1. The March MAR for resident 1 did not include the reason Lorazepam was given on 3/18/2023 at 1:20 pm. 2. The March MAR for resident 2 did not include the reason Tylenol was given on 3/11/2023 at 2:57 pm. 3. The progress notes for resident 3 indicated Quetiapine Fumarate was administered on 1/12/2023 at 1:36 pm, 4:45 pm, 7:51pm and 11:44 pm; on 1/17/2023 at 11:56 pm and 3/26/2023 at 8:45 pm; however, the January and March MARs were blank on all of these dates.
Plan of Correction:	Education will be provided to all nurses and registered medication aides (RMAs) by registered nurse (RN) on proper process for documenting medication administration, including the requirements for as-needed (PRN) medication administration which includes reason for administration and effectiveness. Weekly audits of MARs will be completed by RN/ care coach for one month to ensure reason for PRN medication administration was documented appropriately. If 95% compliance not achieved, audits will continue weekly until 95% compliance is achieved for one consecutive month and then will move to monthly.
Standard #:	22VAC40-73-680-K
Complaint related:	Yes
Description:	Based upon documentation, the facility failed to ensure all as-needed (PRN) orders included the specific symptoms for administering medications and what to do if symptoms persist for three of three resident records reviewed. Evidence: 1. Resident 1?s signed physician?s orders for Bisacodyl (2/21/2023) and Lorazepam (3/18/2022 and 7/19/2022) did not include what to do if symptoms persist and the order for Lorazepam also did not include symptoms that indicate the use of the medications. 2. Resident 2?s signed physician?s orders for Colace (2/24/2023) and Tylenol (2/14/2023) did not include what to do if symptoms persist and the symptoms that indicate the use of the medications. 3. Resident 3?s signed physician?s orders for Furosemide (2/18/2023) and Quetiapine Fumarate (1/10/2023) did not include what to do if symptoms persist and the symptoms that indicate the use of the medications.
Plan of Correction:	A full audit was performed by RN on all facility residents PRN orders for completion. New orders were obtained to include the specific symptoms for administering medications and what to do if symptoms persist. Education will be provided to all nurses and medication aides by RN on the Virginia assisted living facility requirements for PRN orders to ensure staff obtaining verbal or written orders ensure those orders meet the requirements. Weekly audits of new PRN orders with be completed by RN/Care coach for one month to ensure all new orders for PRN medications are complete. If 95% compliance not achieved, audits will continue weekly until 95% compliance is achieved for one consecutive month and then will move to monthly.