VIRGINIA DEPARTMENT OF SOCIAL SERVICES

MC Warrenton Management, LLC
33 Woodlands Way
Warrenton, VA 20186
(540) 242-5236

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Oct. 22, 2024

Complaint Related: Yes

Areas Reviewed:

Administration and Administrative Services Resident Care and Related Services

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: 10/22/2024 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: 59 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: LI observed residents in activity programs. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Administration and Administrative Services and Resident Care and Related Services. A violation notice was issued. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to review and update a written fall risk rating after a fall. Evidence: 1. There was no fall risk rating available for Resident 1 after a fall on 6/24/2024. 2. Staff 2 stated ?we have not been doing post fall risk ratings?.
Plan of Correction:	All staff to complete post fall Morse fall risk rating. Post fall risk rating will be triggered in PCC after a fall incident for documentation.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to administer medications in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. Resident 1 admitted 6/22/2024 did not receive any prescribed medications until 6/25/2024. The Medication Administration Record for Resident 1 for June 2024 indicates the following medications were not administered until 6/25/2024: Atorvastatin tab 40 mg, Bumetanide tab 1 mg, Floranex tab, Levothyroxin tab 25 mg ER, Metroprol Suc tab 50 mg ER, Sertraline tab 25 mg, and Xarelto tab 15 mg. 2. Communication log for Resident 1 for 6/24/2024 has a written note stating, ?meds not here on way per DON? and on 6/25/2024 a note stating, ?meds still not here?.
Plan of Correction:	Medication will be provided in the building prior to admission of the resident. Paper Emar will be available to document the medications administered (as needed). Community will ensure medications are received prior to residents admission.
Standard #:	22VAC40-73-930-D
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to for each resident with an inability to use the signaling device, document the rounds that were made, which shall include the name of the resident, the date and time of the rounds and the staff member who made the rounds. Evidence: 1. There were no documented rounds available for Resident 1. 2. Staff 2 stated documented rounds have not been kept.
Plan of Correction:	Staff document rounds completed during their shift. All records of documented rounds will be kept safely. Community will have staff document in Point of Care to include time, date and staff who made the round.