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 28, 2024 and May 29, 2024

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 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

None

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/28/2024 8:30am ? 4:49pm, 05/29/2024 08:30am ? 12:45pm 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: 74 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: The Licensing Inspector observed the residents during activities, meals and in their apartments and the staff during daily duties and medication administration. The Licensing Inspector reviewed the following at the time of inspection: Menus, activity calendars, fire drills, emergency drills, resident council minutes, dietician report, healthcare oversight, and pharmacy review. Additional Comments/Discussion: 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review and staff interview, the facility failed to ensure a physical exam is completed within 30 days prior to admission. Evidence: 1. Resident 4 (Admitted 6/28/2023) has a physical exam dated 04/19/2023. 2. Staff 1 stated ?That?s the only one we have?
Plan of Correction:	Staff has been re-educated on the required documents for admission. The physical exam was located and filed in resident?s chart. Future admissions will be checked by the Administrator to ensure all required documents are obtained.
Standard #:	22VAC40-73-700-1
Description:	Based on record review and staff interview, the facility failed to ensure oxygen orders contain all required information. Evidence: 1. Resident 4 has an oxygen order dated 5/8/2024 that states ?oxygen 2-4L/min for SOB?. There order does not contain the source or the delivery device. 2. Staff 1 stated ?the order is missing the information?
Plan of Correction:	Staff has been re-educated on the information required for a valid oxygen order. New orders are being reviewed by Clinical Support Specialist to ensure compliance. This order has been corrected.
Standard #:	22VAC40-73-860-I
Description:	Based on direct observation and staff interview, the facility failed to ensure cleaning supplies and hazardous chemicals are stored in a locked area. Evidence: 1. Two licensing staff observed the laundry room door in the secured unit, unlocked and containing 2 bottles of cleaner on a shelf and a bottle of laundry detergent on the counter. 2. Inside of the laundry room was an additional closet unlocked and containing an unlocked and open cleaning cart with multiple bottles of cleaning supplies as well as a shelf, and bucket containing multiple bottles of cleaning supplies. 3. Staff 4 stated ?it was left unlocked?. 4. Photo evidence taken
Plan of Correction:	Staff has been re-educated on the standards for cleaning supplies and hazardous chemicals. Laundry room and other storage areas will be checked for compliance daily by the Administrator.
Standard #:	22VAC40-73-970-A
Description:	Based on record review and staff interview, the facility failed to ensure fire drills are completed on each shift in a quarter in accordance with the Virginia Statewide Fire Prevention Code (13VAC5-51). Evidence: 1. Staff 1 confirmed the facility shifts include shift 1 as 7am ? 7pm and shift 2 as 7pm ? 7am. 2. Fire drill documentation shows the fire drills for quarter 1 of 2024 as 1/31/24 at 3:30pm (Shift 1), 2/21/2024 at 10:00am (Shift 1), and 3/20/2024 at 3:00pm (Shift 1).
Plan of Correction:	Staff has been re-educated on the standards for fire drills. A fire drill for the 7pm-7am shift was completed on 05/31/2024. Lead Maintenance will continue to ensure drills are completed on each shift, 7am ? 7pm and 7pm ? 7am.