VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Warren
935 S Ox Road
Woodstock, VA 22664
(540) 459-2525

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: Nov. 8, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 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: LI entered the facility at 8:45 am on 11/8/2023 and exited at 12:55 pm. 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 (10/26/2023 regarding allegations in the area(s) of general provisions, administration and administrative services, and resident care and related services. Number of residents present at the facility at the beginning of the inspection: 39 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based upon a review of records, the facility failed to follow their medication management policy to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. Evidence: 1. According to the facility?s medication management plan under the narcotic section on page 5, ?Two community certified staff members who are authorized to administer medications will complete a controlled drug count at the beginning and ending of each shift.? 2. The controlled drug count sheets reviewed for November 2023 did not document that two people completed the controlled drug count at the beginning and ending of each shift.
Plan of Correction:	Resident Wellness Director with support of Resident Care Director and/or designee will ensure each Medication Aide is in-serviced on Inspirit Senior Living Medication Management Policy for counting off medication carts at the beginning and ending of each shift, documenting in the shift sign off sheet and ensuring that two registered medication aides complete the count. Executive Director will provide oversight to ensure compliance.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on a review of records during a complaint inspection on 11/8/2023, the facility failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. Resident 1 (R1) has a signed physician?s order to receive Clonazepam 1mg three times a day. 2. The Controlled Drug Administration Sheet for September 2023 for R1 documents that Clonazepam was not administered to R1 on: 9/2/2023 at approximately 2 pm, on 9/4/2023 at approximately 10:00 pm; 9/9/2023 at approximately 2 pm; and 9/20/2023 at approximately 10 pm. 3. According to documentation on the September 2023 MAR for Resident 2, on 10/18/2023 the 2 pm scheduled dose of Hydrocod/APAP ?medication was not given, and dose was missed.?
Plan of Correction:	Resident Care Director and or designee will ensure the medication refresher that is scheduled by 11/30/2023 that is consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing on documentation and medication passing be completed. Executive Director will provide oversight to ensure compliance.
Standard #:	22VAC40-73-680-I
Complaint related:	Yes
Description:	Based on interview with the administrator, the facility failed to ensure the Medication Administration Record (MAR) included initials of direct care staff administering the medication. Evidence: 1. During an interview at approximately 12:40 pm on 11/8/2023, the administrator reported: ? On the MAR for 9/20/2023, no initials of direct care staff administering medications were entered onto the MAR for the 10pm dosage of Clonazepam for R1 on 9/20/2023. ? The September 2023 MAR was altered on 10/23/2023, by a staff person, who is not direct care staff at The Warren, to reflect that Clonazepam had been given at approximately 10 pm on 9/20/2023 to R1 and the initials entered on the MAR were for a direct care staff member who was not working that day and time. ? The administrator confirmed that when it was discovered that it was a different staff person who was working on 9/20/2023 at approximately 10 pm, the initials on the MAR were changed again to those of the direct care staff person who was listed on the work schedule for that day and time.
Plan of Correction:	Resident Care Director and or designee will ensure understanding for documenting in the MAR when medications are administered or reporting if meds not given as outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Resident Care Director and or designee will ensure that any outside person coming into provide an oversite will meet to discuss concerns of findings from the audit before amending any records. Executive Director will provide oversight to ensure compliance.