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: May 8, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 BUILDINGS AND GROUND

Technical Assistance:

Recommended replacing the carpet in the rooms that have a urine smell.

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: 5/8/2023 from approximately 10:00 am to 11:50 am 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 4/28/2023 regarding allegations in the areas of: Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 8 Observations by licensing inspector: Resident rooms and common areas on the secured unit and common areas on the assisted living unit. Additional Comments/Discussion: Family members were also interviewed as well as outside agency staff. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were 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.virgiia.gov@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-870-B
Complaint related:	Yes
Description:	Based upon observations and interviews, the facility failed to ensure all areas remained free of foul odors. Evidence: 1. On 5/8/2023, the licensing inspector (LI) and staff 1 conducted room checks on the secured unit and the rooms for resident 2 and 3 both smelled of urine. Resident 3?s room also had feces on the carpet next to his bed. 2. On 5/8/2023, the LI interviewed staff 1 and 2 and both stated the rooms for residents 2 and 3 smelled of urine and that feces was observed on resident 3?s carpet. Staff 2 stated there was feces on the carpet at 7:00 pm the previous day (5/7/2023) and staff tried to clean it up with wipes, Sani-cloths, and soapy paper towels. Staff 2 stated resident 2?s room smelled of urine sometimes but resident 3?s room smelled of urine all the time. 3. On 5/8/2023, the LI interviewed staff 3 and 4 and both stated resident 3 had a bowel movement and they cleaned him up and reported to housekeeping that there was feces on the carpet. Both staff stated it was reported to housekeeping over the weekend that there was feces on resident 3?s carpet. 4. On 5/8/2023, the LI interviewed collateral 1 who stated resident 2?s room often smelled of urine when entering and that it was reported to staff. 5. On 5/8/2023 at the LI interviewed collateral 2 who stated feces was on the carpet when she arrived to resident 3?s room and that ?the room smells like urine pretty much every time I come.?
Plan of Correction:	Housekeeping cleaned all units cited. Housekeeping is scheduled specifically to these rooms that require additional cleaning and will be documented. Maintenance is shampooing the units and hallways at a minimum weekly and additionally if needed. The Maintenance Manager is monitoring daily to ensure compliance and monitoring all units during daily rounds.