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: July 28, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Ensure staff carefully review all paperwork prior to filing.

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: 7/28/2022 from approximately 8:55 am to 9:45 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 7/21/2022 regarding allegations in the area of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 62 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Secured unit 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; the area(s) of non-compliance with standards or law were in the area of 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-E
Description:	Based upon documentation and an interview, the facility failed to ensure a medical procedure for one of one resident record reviewed was completed as ordered. Evidence: 1. Resident 1 had a physician?s order (signed 7/6/2022) for a sacral x-ray ? two views and a Lidocaine patch. 2. On 7/21/2021, the licensing inspector (LI) interviewed staff 1 via telephone and she stated she received the signed physician?s order on 7/6/2022 and faxed the order to the pharmacy but missed the request for the x-ray. She stated on 7/12/2022 the physician contacted the facility for the results of the x-ray and the x-ray had not been requested.
Plan of Correction:	1. The x-ray for this resident has been performed and results discussed with family. 2. The Director of Health and Wellness, or designee, will review physician?s orders five times per week to ensure no missed orders. The Director of Health and Wellness will submit results of the audits to the Executive Director for review. 3. The Executive Director and Director of Health and Wellness will be responsible for the implementation and monitoring of this plan. The Executive Director will review the audit results and address 4. Date by which plan of correction will be fully implemented and noncompliance will be corrected: Friday, August 26, 2022