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: Dec. 6, 2022 , Dec. 7, 2022 and Dec. 8, 2022

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 ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 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. Carefully review all forms prior to filing to ensure all information is accurate and complete (fire drill forms, facility assessment/interview forms, initial physicals, etc. 2. Recommended having all direct care staff complete the 10 hours of dementia training within the first four months of hire. 3. Ensure staff 4 completes the emergency preparedness training before the end of December. 4. Ensure residents sign the orientation form that is reviewed on the day of admission ? even if resident has a serious cognitive impairment ? the family member may also sign but may not sign in place of the resident. 5. Reviewed sections of the uniform assessment manual with the director of health and wellness and answered questions. 6. Clarify on the facility assessment/interview form what is reviewed regarding the sex offender registry (refer to standard 350.C and D).

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/6/2022 from approximately 7:30 am to 5:25 pm, 12/7/2022 from approximately 7:00 am to 5:30 pm and 12/8/2022 from approximately 11:45 am to 4:30 pm. 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: 58 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 + selected sections of 6 additional records Number of staff records reviewed: 4 + selected sections of 7 additional records Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 6 Observations by licensing inspector: medication administration, medication carts, activities, meals, staffing, special diets, staff/resident interactions, required postings, Additional Comments/Discussion: There were 58 residents in care, 20 on the secured unit and 38 on the assisted living unit. Upon receipt of the annual fire and health inspection reports, please forward a copy of each to this inspector. 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 Janice Knight, Licensing Inspector at (540) 430-9268 or by email at janice.knight@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1110-B
Description:	Based upon documentation and an interview, the facility failed to ensure three of the three residents? records reviewed included a six-month or annual review of appropriateness for placement in a secured unit. Evidence: 1. Resident 1 (admitted 12/28/2021) and resident 3 (admitted 1/20/2022) did not have a six-month review completed and on file. 2. The last review completed for resident 2 (admitted 9/30/2020) was dated as completed on 11/17/2021. 3. On 12/7/2022, the LI interviewed staff 13 who stated the reviews for appropriateness for continued placement in the secur4ed unit had not been completed.
Plan of Correction:	DHW and director of innovations memory care (DIMC) to audit appropriateness for placement in a secured unit forms on a monthly basis. DHW and/or DIMC to share audit results with ED. 1/8/2022. To be monitored by DHW, DIMC, and ED.
Standard #:	22VAC40-73-1140-B
Description:	Based upon documentation and an interview, the facility failed to ensure three of the four staff records reviewed completed at least 10 hours of dementia training within the first four months of hire. Evidence: 1. The training record for staff 1 (hired 5/3/2021) listed 7.50 hours of dementia training completed. 2. The training record for staff 2 (hired 8/9/2022) listed 6.0 hours of dementia training completed. 3. The training record for staff 4 (hired 7/26/2021) listed 6.25 hours of dementia training completed.
Plan of Correction:	BOM or ED to schedule dementia training for Staff 1, 2, and 4 immediately. At orientation, BOM or designee to assign/schedule dementia training to be completed over following 4 months for each new direct care staff. 1/8/2022. To be monitored by BOM and ED.
Standard #:	22VAC40-73-260-A
Description:	Based upon record reviews and an interview, the facility failed to ensure three of the 10 staff records reviewed had documentation of completion of first aid (FA) certification within 60 days of hire. Evidence: 1. Staff 8 (hired 3/28/2022), staff 10 (hired 7/25/2022) and staff 11 (hired 8/4/2022) had not completed FA training. 2. On 12/8/2022, the LI interviewed the business office manager (BOM) who stated these three staff had not completed the FA training.
Plan of Correction:	BOM and/or designee to ensure first aid certifications are obtained during orientation and will audit first aid certifications weekly for needed certifications and expired certifications. Certifications to be discussed during Weekly Management Meeting. Schedule classes as needed to provide appropriate training, 1/8/2022. To be monitored by BOM and executive director (ED).
Standard #:	22VAC40-73-260-C
Description:	Based upon observations, documentation and an interview, the facility failed to ensure the posted list of staff with FA and cardiopulmonary resuscitation (CPR) remained current. Evidence: 1. On 12/6/2022, the BOM submitted to LI a list of staff and their hire dates. The list included staff 2, 6, 7 and 9 who were newly hired direct care staff/nurses. 2. On 12/6/2022, the LI observed the posted list of staff with certifications in FA and CPR in the nurses? office located behind the concierge desk. The list did not include staff 2, 6, 7 and 9. 3. On 12/8/2022, the LI interviewed the BOM who stated the list had not been updated and the new staff hired with certifications had not been added to the list.
Plan of Correction:	BOM and/or designee to audit first aid/CPR certifications weekly for needed certifications and expired certifications and make sure correct current list is posted. Certifications to be discussed during Weekly Management Meeting. 1/8/2022. To be monitored by BOM and ED.
Standard #:	22VAC40-73-860-I
Description:	Based upon observations and an interview, the facility failed to ensure cleaning supplies were stored in a locked area. Evidence: 1. On 12/6/2022, the licensing inspector (LI) and staff 4 were conducting a tour of the secured unit and the soiled linen closet door was observed closed but unlocked and unattended. 2. The LI and staff 4 observed multiple containers of cleaning supplies (Germicidal cleaner, disinfectant spray, etc.) on the shelf in the unlocked closet.
Plan of Correction:	The storage room door was locked immediately by staff 4. Director of environmental services (DES) will compete an in-service with all housekeeping associates and ensure they understand the importance of storing all cleaning supplies in a locked area. 1/8/2022. To be monitored by DES and ED
Standard #:	22VAC40-73-950-E
Description:	Based upon documentation and interviews, the facility failed to ensure two of the seven resident records reviewed had signed documentation of a six-month review of the emergency preparedness plan. Evidence: 1. On 12/8/2022, the LI reviewed the assessment/interview forms in each resident record, which included the emergency preparedness training review. The forms on file for residents 4 and 5 were not signed by the residents. 2. On 12/8/2022, the LI interviewed the administrator who stated there was no other documentation on file for completion of the emergency preparedness training for these two residents.
Plan of Correction:	Director of health and wellness (DHW) to ensure that six-month reviews of the emergency preparedness plan for residents 4 and 5 be conducted immediately. DHW and/or designee to audit charts monthly for emergency preparedness reviews that are due. 1/8/2022. To be monitored by DHW and ED
Standard #:	22VAC40-73-970-E
Description:	Based upon documentation and interviews, the facility failed to ensure all required information was documented on two of twelve fire drill forms reviewed. Evidence: 1. On 12/6/2022, the LI reviewed the monthly fire drill forms and the forms for 3/1/2022 and 11/18/2022 did not include the number of staff and residents participating in the drills. Both sections of the forms were blank. 2. On 12/6/2022, the LI interviewed staff 12 who confirmed the two sections of the fire drill forms were blank and the information had not been documented. 3. On 12/8/2022, the LI reviewed the two fire drill forms with the administrator who also confirmed the two sections of the forms were blank.
Plan of Correction:	DES to be educated by ED immediately on ensuring all required information is documented on fire drill forms. Forms to be thoroughly reviewed by ED after fire drills to ensure accurate completion. 1/8/2022. To be monitored by DES and ED.