VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Regency at Augusta
43 Pinnacle Drive
Fishersville, VA 22939
(540) 213-4400

Current Inspector: Jill James (540) 418-2631

Inspection Date: Nov. 30, 2021 , Dec. 1, 2021 and Dec. 2, 2021

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 63.2 General Provisions. 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:

1. The staff schedule must indicate the staff member that is in charge every day for each shift. 2. Criminal record reports must be completed when a staff is rehired and should be completed prior to hire. 3. The resident orientation form must be signed by the resident and the legal representative (if applicable) but not in place of the resident. 4. Recommended all staff carefully review all paperwork prior to filing to ensure all information is accurate and complete and that blanks are filled in with the requested information (or put "not applicable" if the requested information does not apply) - such as do not resuscitate orders, physicals, etc. 5. Reviewed the fire drill requirements with the maintenance staff who conducted the fire drills. 5. Recommended adding a place on the individualized service plans (ISPs) for the residents to sign for verification that a copy of the plan was issued to them. 6. Recommended conducting an audit of the uniform assessment instruments (UAIs) and ISPs to ensure all needs are addressed and that the specific services to be provided for each activity are clearly listed. 7. Only check one area under medication management on the UAIs. Administered by a lay person must be checked when the medications are administered by a registered medication aide rather than checking "administered by professional nursing staff". 8. The frequency of safety/wellness checks was clearly documented on the ISPs; however, physical/mental inability to use the call bell was not specifically stated and needs to be included on the ISPs. 9. Recommended additional audits of the medication cart be conducted by the director of health and wellness or executive director to ensure the audits are being completed as the facility policy requires.

Comments:

An unannounced renewal inspection was conducted on 11/30/2021 from approximately 8:24 am to 5:20 pm, 12/1/2021 from approximately 8:15 am to 5:10 pm and 12/2/2021 from approximately 8:10 am to 5:05 pm. There were 54 residents in care, including 19 in the secured unit. The facility was clean and free from any foul odors. The posted menu accurately reflected this inspector's observations and the special diet observed in the memory care unit was served according to the physician's order. Medication administration observations were conducted with the registered medication aides on the assisted living and secured units for a total of four residents. The November 2021 medication administration records, physicians' orders and medications were reviewed for all four residents. Eight resident, one discharge and five staff records were reviewed. Selected sections of one additional resident and staff were also reviewed. The criminal record reports for all current staff hired since the last inspection were reviewed. Individual interviews were conducted with residents, a family member and staff. The areas of noncompliance included staff schedules, individualized service plans, documentation provided to emergency personnel, implementation of medication management policy, self-administering medications, oxygen orders, fire drills and criminal record reports. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-290-A
Description:	Based upon documentation and an interview, the facility failed to ensure the written work schedule included all required information. Evidence: 1. The staff schedule for 11/14/2021 through 11/27/2021 did not indicate the staff in charge at any time. 2. On12/2/2021, the LI interviewed the ED who stated the staff person in charge was not included on the staff schedule.
Plan of Correction:	The ED will ensure that the written work schedule will reflect the staff person in charge on each shift. The written work schedule was re-printed on 12/8/21 to indicate the staff person in charge at any given time. Staff person in charge has been added to the schedule on a separate row to indicate who is in charge for each shift. The ED does schedules and the director of health and wellness (DHW) will review prior to posting to ensure compliance.
Standard #:	22VAC40-73-450-C
Description:	Based upon documentation and interviews, the facility failed to ensure all assessed needs were included on the individualized service plans (ISPs) for six of eight resident records reviewed. Evidence: 1. The uniform assessment instrument (UAI) completed 11/8/2021 indicated resident 2 required mechanical help with transferring and supervision with eating; however, these needs were not listed on the ISP completed on 11/23/2021. 2. The UAI completed 9/23/2021 indicated resident 3 required mechanical help with toileting; however, this need was not listed on the ISP completed on 9/23/2021. Resident 3 was also receiving hospice services and hospice was listed on the ISP; however, the specific services being provided were not listed on the ISP. 3. The UAI completed 10/20/2021 indicated resident 5 required mechanical help with bathing and eating, mechanical help and physical assistance with transferring, and assistance with wheeling; disorientation to time/event and passive wandering; however, these needs were not listed on the ISP completed on 10/20/2021. 4. The UAI completed 11/16/2021 indicated resident 6 required mechanical help with transferring; however this need was not listed on the ISP completed 11/16/2021. 5. On 12/1/2021, the LI interviewed the ED and DHW and both stated the ISPs did not list all of the needs assessed on the UAIs for these residents. The DHW stated, "I was trying to get them done too quickly."
Plan of Correction:	The ISPs for residents 2, 3, 5 and 6 were updated to include assessed needs. The ISP for resident 3 was updated to include the specific services provided by hospice. A workshop was held on 11/23/21 for staff members who conduct assessments and create ISPs. The training provided guidance on including assessed needs from the UAI and other sources on the ISP. The ED will ensure that all ISPs include the assessed needs as well as all services provided to the residents. The DHW will create all UAIs and ISPs and the ED will review all for approval. All current ISPs are actively being reviewed to ensure all assessed needs, other needs, and services provided are clearly listed.
Standard #:	22VAC40-73-570-D
Description:	Based upon an interview, the facility failed to ensure all required information was given to emergency personnel. Evidence: On 11/30/2021, the LI interviewed the ED regarding what information staff have been instructed to give emergency personnel when a resident is being transported to the hospital. The ED stated the physicians' order sheets were given and not the medication administration records or similar documentation.
Plan of Correction:	The standard lists "Medication Administration Record" as an "example" of the type of information necessary to the care of the resident when hospitalized or transported by emergency personnel. The facility policy Clinical 12 - Medical Emergencies lists the following information to be provided to paramedics: a Hospital Facility Transfer Form (completed); a list of current medications, DNR status (Advance Directives/Care Orders/POST, etc.) and the Face Sheet Form. The staff have been instructed to provide this information as well as to provide the "Last Dose Administered Report." A checklist was also created and DHW will review each transport with staff.
Standard #:	22VAC40-73-640-A
Description:	Based upon documentation, observations and interviews, the facility failed to implement the medication management plan by ensuring medications were readily available for three of four residents. Evidence: 1. Resident 4 had a physician's order signed 9/22/2021 for Acetaminophen. 2. The November medication administration record (MAR) for resident 4 listed, "Acetaminophen 325mg two tablets by mouth every 4 hours as needed for pain/fever." 3. On 11/30/2021, the LI and staff 5 conducted an audit of resident 4's medications and staff 5 stated she could not find the Acetaminophen in the medication cart. 4. Resident 8 had a physician's order signed 11/12/2021 for Mucinex. 5. The November MAR for resident 8 listed, "Mucinex DM 30/600mg one tablet by mouth every 6 hours as needed for cough/congestion." 6. On 11/30/2021, the LI and staff 9 conducted an audit of resident 8's medications and staff 9 could not find Mucinex in the medication cart. 7. Resident 9 had a physician's order signed 10/5/2021 for Ondansetron. 8. The November MAR for resident 9 listed, "Ondansetron HCl 4mg one tablet under tongue every 6 hours as needed for nausea." 9. On 11/30/2021, the LI and staff 9 conducted an audit of the medications for resident 9 and staff 9 could not find the Ondansetron in the medication cart. 10. On 11/30/2021, the LI interviewed the nursing supervisor who stated the medications were not in the medication room and were not available on site. 11. The facility's medication management plan stated on page 6, section 10.c, "Night shift nurse will check PRN meds weekly during cart audits and request refills as needed to ensure adequate supply."
Plan of Correction:	The PRN (as-needed) medications that were not in the medication cart have been provided by the pharmacy and are now at the community. The medication for resident 9 was found by the day shift supervisor in the medication cart the next day after the licensing inspector had finished her audit. The medication management plan has been adjusted to reflect that the weekly cart audits may be completed by the nurse or registered medication aide (RMA) on evening shift, night shit, or any shift assigned. This process will enable the ED to ensure compliance and to adjust the weekly audit duties based on the needs of the community. The ED will review the results of the medication cart audits weekly for the next six weeks (until 1/21/22) to ensure compliance. The pharmacy will create a "PRN" report to send to DHW on a monthly basis to review and to ensure all medications are present and still current. Medication cart audits will be done weekly and reviewed by DHW prior to turning in to be reviewed by the ED weekly.
Standard #:	22VAC40-73-660-B
Description:	Based upon documentation, observations and interviews, the facility failed to ensure one of eight resident records reviewed was assessed as capable of self-administering and keeping medications in the room. Evidence: 1. The UAI (completed 11/16/2021) assessed resident 6 as needing medications to be administered/monitored by professional nursing staff. 2. The ISP (completed 11/16/2021) for resident 6 indicated, "Resident self administers medications and keeps medications in a secure location." 3. The initial physical (completed 7/21/2021) for resident 6 indicated resident was capable of self-administering medications. 4. On 12/2/2021, the LI interviewed resident 6 who stated she keeps medications in her room. Resident 6 also showed the LI where she keeps the medications in her room. 5. On 12/2/2021, the LI interviewed staff 8 who completed the UAI and ISP for resident 6 and she stated she checked the wrong section in error and was trying to do them too quickly.
Plan of Correction:	The UAI has been corrected to reflect the ability of resident 6 to self-administer medications. All residents that self-administer have been re-assessed and any needed corrections have been made. The DHW will correctly assess each resident prior to move in and then monthly. The ED will review all assessments to ensure compliance.
Standard #:	22VAC40-73-700-1
Description:	Based upon documentation and an interview, the facility failed to ensure two of three oxygen orders had all required information. Evidence: 1. The oxygen orders for residents 7 (signed 11/14/2021 and 10 (signed 10/13/2021) did not include the source of the oxygen. 2. On 12/1/2021, the LI interviewed the ED and DHW and both stated the source was not included on these two oxygen orders.
Plan of Correction:	The physician has re-written (on 12/8/21) the orders for resident 7 and resident 10 to include the source of the oxygen. The ED will review, with all nurses and registered medication aides, the policy Med 27 - Assistance with Oxygen, which includes details regarding information required in the orders. The DHW has created a form for "continuous" as well as "PRN" oxygen to be signed by physician to include all needed information. The signed oxygen orders will be reviewed by the ED monthly.
Standard #:	22VAC40-73-970-A
Description:	Based upon documentation and an interview, the facility failed to ensure fire drills were conducted on each shift in a quarter. Evidence: 1. Fire drill forms indicated fire drills were held in the same quarter on the same shift on 8/27/2021 at 2:30 pm, 9/2/2021 at 10:30 am and 10/4/2021 at 1:22 pm. 2. On 12/1/2021, the LI interviewed staff 7 who stated, "I wasn't aware that I had to conduct a drill on each shift."
Plan of Correction:	The ED has created a schedule for required fire drills to ensure that they are scheduled on each shift in a quarter. The standard was reviewed with staff 7. The ED will meet with staff 7 monthly to review needs prior to the fire drill being conducted. Staff 7 will then review each completed fire drill form with ED for compliance.
Standard #:	22VAC40-90-40-B
Description:	Based upon documentation and an interview, the facility failed to ensure one of 52 criminal record reports (CRR) was completed within 30 days of hire and no more than 90 days prior to hire. Evidence: 1. The CRR for staff 6 (rehired 10/19/2021) was completed 6/3/2021. 2. On 11/30/2021, the licensing inspector (LI) interviewed the executive director (ED) who stated a new CRR was not completed when staff 6 was rehired.
Plan of Correction:	The ED has reviewed with the business office manager (BOM) that a new CRR must be completed again when a former employee is rehired. An audit was conducted on all employee files to ensure compliance. A CRR was conducted for staff 6 on 12/01/21. The BOM will complete a new hire/rehire checklist at every hire and turn in weekly to the ED for review.